New Orleans medical and surgical journal

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NEW ORLEANS
MEDICAL AND SURGICAL
JOURNAL

VOLUME NINETY-SEVEN

★

JULY, 1944
through
JUNE, 1945

NEW ORLEANS

Med ical and Surgical Journal

Established 1844

Published by the Louisiana State Medical Society
under the jurisdiction of the following named
Journal Committee:

Yal H. Fuchs, M. D., Ex officio
For two years: G. C. Anderson, M. D., Chairman
Leon J. Menville, M. D.

For one year: J. K. Howies, M. D., Vice-Chairman
For three years: C. Grenes Cole, M. D., Secretary
E. L. Leckert, M. D.

' : EDITORIAL STAFF

J ohn H. .Mus.se}-, . M. D Editor -in-Chief

Willard 31.. Wirth, M. D. Eaitor

Max M. Greet:, M. D — Associate Editor

COLLABORATORS— COUNCILORS

Edwin L. Zander, M. D.

J. T. O’Ferrall, M. D.

Guy R. Jones, M. D.

T. B. Tooke, Sr., M. D.

George Wright, M. D.

W. E. Barker, Jr., M. D.

C. A. Martin, M. D.

W. F. Couvillion, M. D.

Paul T. Talbot, M. D General Manager

1430 Tulane Avenue

SUBSCRIPTION TERMS: $3.00 per year in ad-
vance, postage paid, for the United States; $3.50
per year for all foreign countries belonging to the
Postal Union.

News material for publication should be received
not later than the eighteenth of the month preced-
ing publication. Orders for reprints must be sent
in duplicate ivhen returning galley proof.

Manuscripts should be addressed to the Editor-
in-Chief, 1430 Tulane Avenue, New Orleans, La.

The Journal does net hold itself responsible for
statements made by any contributor.

Index

III

INDEX TO VOLUME NINETY-SEVEN

July, 1944 — June, 1945

— A —

Agee, Owen F. — The treatment of early syphilis by means of eight weeks’ mapharsen ther-
apy with bismuth 134

Aging, the physiologic and clinical phenomena of, by Ernst P. Boas 64

Alexander, Lucian W. — Sinus disease producing monocular proptosis 351

Amebiasis, treatment of, by Juan Arosemena 392

Aneurysm, dissecting, of the aorta in a boy, by J. W. McLaurin 317

Arosemena, Juan — Treatment of amebiasis 392

Arrhenoblastomata, ovarian, by C. Gordon Johnson ; < 526

Ascorbic acid intake, inadequate, the effects of, by Henry R. Hyslop 452

— B—

Bendel, William L. — Pelvic inflammatory diseases 248

Billings, Terrece E. — The combined use of fever and chemotherapy in syphilis 127

Blood transfusion substitutes: present status, by Gordon A. Nicoll 211

Boas, Ernst P. — The physiologic and clinical phenomena of aging 64

Bodenheimer, Jacob M. — Ruptured intestines, the results of non-penetrating trauma 383

Book reviews 38, 87, 148, 192, 240, 288, 332, 381, 431, 477, 520, 570

Boyce, Frederick Fitzherbert — Further observations on carcinoma of the stomach in a large

general hospital 217

Bronchoscopy, the diagnostic and therapeutic possibilities of bronchoscopy, by George J.

Taquino 291

Brown, R. Alec — Thirty-five millimeter fluorography in mass chest x-ray surveys 4

Browne, Donovan C. — (Joint author), see McHardy, Gordon 501

Brucellosis, general considerations of, by Harry J. Schmidt 256

Burch, George E. — A clinico-pathologic conference (Burch, Dunlap) 504

Burns, Edgar — Prostatic obstruction and some of its common complications 243

— C^-

Cancer clinic at Charity Hospital, yearly report of the, by Alton Ochsner and Maxwell F. Kepi 277

Cannon, Paul R. — Food: facts and fads 17

Carcinoma of the larynx, by Francis E. LeJeune 298

Carcinoma of the stomach, in a large general hospital, further observations on, by Frederick

Fitzherbert Boyce 217

Carruthers, F. Walter — Management of certain types of fractures involving the shaft of long

bones 197

Cataract surgery, important considerations in, by George M. Haik 345

Cellulitis, orbital, with severe cerebral symptoms, by Jerome Romagosa and G. D. Rackley 276 ■

Chaille, Doctor Stanford E., in memoriam, by Thomas S. Kavanagh 433

Chemotherapy, local and systemic, and its relationship to the fundamental requirements of

compound fractures, by H. Winnett Orr. 201

Chest x-ray surveys, thirty-five millimeter fluorography in, by R. Alec Brown 4

Clinico-pathologic conference, Charity Hospital, New Orleans 72

Clinico-pathologic conference, Charity Hospital, New Orleans 227

Clinico-pathologic conference, by George E. Burch and Charles E. Dunlap 504

Clinico-pathologic conference, by J. L. Wilson and C. E. Dunlap 552

Colitis, atypical amebic, by Daniel N. Silverman and Alan Leslie 435

— D —

D’Antoni, Joseph S. — The dysenteries - 101

Dempsey, C. S. — (Joint author), see Musser, J. H 180

Diagnosis and treatment of medical emergencies, by Maridel Saunders 531

Diagnosis of disease without instruments of precision, by Ralph H. Major 49

Diarrheal disorders, acute, the diagnosis and treatment of, by James Watt 438

D’lngianni, Vincente — Intestinal obstruction following the use of cotton 322, 503

IV

Index

Disks, ruptured intervertebral, by John D. Lane - 270

Dunlap, Charles E. — (Joint author), see Burch, George E - 504

Dunlap, C. E. — (Joint author), see Wilson, J. L - 552

Dysenteries, the, by Joseph S. D’Antoni - 101

— E—

Eddy, James H., Jr. — March fracture in industry - 171

Editorials 30, 79, 140, 182, 232, 279, 324, 370, 420, 466, 510, 560

Encephalitides of North America, the arthropod- borne, by J. L. Henderson 22

Endocrinologicus, status, by Leonard B. Shpiner 205

Englehardt, H. T. — (Joint author), see Sodeman, W. A 307

— F—

Faust, Ernest Carroll — Filariasis and schistomiasis 115

Faust, Ernest Carroll — Tropical medicine in the United States as a result of the war >..... 93

Felknor, George — (Joint author), see Pullen, R. L 359

Fever, Rocky Mountain spotted, by R. L. Pullen, W. A. Sodeman, and George Felknor. 359

Filariasis, a future problem in the United States, by Charles D. Knight 406

Filariasis and schistomiasis, by Ernest Carroll Faust 115

Food: facts and fads, by Paul R. Cannon 17

Food poisoning, by George H. Hauser. 362

Fractures, compound, chemotherapy, local and systemic, and its relationship to the fundamen-
tal requirements of, by H. Winnett Orr 201

Fractures involving the shaft of long bones, management of certain types of, by F. Walter

Carruthers 197

Fracture, march, in industry, by James H. Eddy, Jr 171

Fracture of the patella — analysis of 150 cases at Charity Hospital, by Lyon K. Loomis 173

— G—

Gaines, Shelley R. — The value of central field studies over the conventional type of visual

field studies 176

Gall stone ileus, by Gordon McHardy and Donovan C. Browne 501

Geiger, J. C. — The health department of the future 479

Green, Marvin T. — Milker’s nodule 13

Gynecology, pediatric, some problems of, by Bernard Weinstein 495

— H —

Haik, George M. — Important considerations in cataract surgery 345

Hauser, George H. — Food poisoning 362

Headache, certain etiologic factors concerned with, by Edgar Warren 389

Health department of the future, the, by J. C. Geiger 479

Heart disease in the Charity Hospital, the incidence of the several etiologic types of, by J. H.

Musser and C. S. Dempsey 180

Hemoflagellate infections, by Harry A. Senekjie 112

Henderson, J. L.— The arthropod-borne encephalitides of North America 22

Hypertension, pathogenesis of, by Wyman P. Sloan, Jr 457

Hyslop, Henry R. — The effects of inadequate ascorbic acid intake 452

— I—

Infant, premature, care of the, at Charity Hospital, by Hazel Pierce and Wallace Sako 163

Ileus, gall stone, by Gordon McHardy and Donovan C. Browne 501

Intestinal function, the effect of vitamins on the, by L. D. Wright, Jr 400

Intestinal obstruction following the use of cotton, by Vincente D’lngianni 322, 503

Intestines, ruptured, the result of non-penetrating trauma, by Jacob M. Bodenheimer 383

Index

V

Johnson, C. Gordon — Ovarian arrhenoblastomata 526

— K—

Katz, Robert A. — Peptic ulcer: psychosomatic and medical aspects 262

Kavanagh, Thomas S. — In memoriam, Doctor Stanford E. Chaille 433

Keloids and scars, production and treatment of, by Wallace Marshall 15

Kepi, Maxwell F. — (Joint author), see Ochsner, Alton 277

King, E. L. — The role of roentgen pelvimetry in the management of pelvic contraction 302

Knight, Charles D. — Filariasis, a future problem in the United States 406

Knight, Harry C. — The present status of the five day intensive treatment of syphilis 131

Kolmer, John A. — Syphilis, the great masquerader 335

Lane, John D. — Ruptured intervertebral disks 270

Larynx, carcinoma of the, by Francis E. LeJeune 298

Leslie, Alan — (Joint author), see Silverman, Daniel N 435

Levy, Walter E. — Special aspects of prenatal care 521

Loomis, Lyon K. — Fracture of the patella — analysis of 150 cases at Charity Hospital 173

Louisiana State Medical Society News 34, 85, 145, 188, 237, 284, 330, 376, 426, 472, 516, 566

— Me—

McHardy, Gordon — Gall stone ileus (McHardy, Browne) 501

McLaurin, J. W. — Dissecting aneurysm of the aorta in a boy 317

— M—

Major, Ralph H. — The diagnosis of disease without instruments of precision 49

Malaria, by A. J. Walker 98

Malaria in military personnel, recurrent, by William D. Stubenbord 120

March fracture in industry, by James H. Eddy, Jr 171

Marshall, Wallace — Production and treatment of scars and keloids 15

Matas, Rudolph-^rThe permanent presence of specific immunizing antibodies in the blood of

yellow fever subjects 9

Medical education, some postwar problems in, by Lewis H. Weed 43

Medical emergencies, diagnosis and treatment of, by Maridel Saunders 531

Meningitis, comparison of incidence and treatment of, over a ten year period, by H. E. Rollings

and J. H. Musser 445

Metz, Waldemar R. — The doctor and specialized medicine 151

Miller, Albert — The distribution and epidemiology of important tropical diseases of the war

areas 93

Moss, Emma S. — (Joint author), see Palik, Emil S 153

Musser, J. H. — The incidence of the several etio logic types of heart disease in the Charity

Hospital (Musser, Dempsey) 180

Musser, John H. — (Joint author), see Rollings, H. E 445

N

Napier, L. Everard — The rickettsia diseases: yellow fever; dengue and sandfly fever 108

Nelken, Sam — What makes medicine psychosomatic? 319

Nicoll, Gordon A.— Blood transfusion substitutes: present status 211

Nodule, milker’s, by Marvin T. Green 13

— O—

Obstruction, intestinal, following the use of cotton, by Vincente D’lngianni 322, 503

Ochsner, Alton — Yearly report of the cancer clinic at Charity Hospital (Ochsner, Kepi) 277

Organization Section 32, 82, 142, 185, 234, 281, 327, 373, 423, 468, 512, 562

VI

Index

Orleans Parish Medical Society Transactions 33, 187, 236, 283, 328, 375, 425, 470, 514, 564

Orr, H. Winnett — Chemotherapy, local and systemic, and its relationship to the fundamental

requirements of compound fractures 201

Ovarian arrhenoblastomata, by C. Gordon Johnson 526

— P—

Palik, Emil E. — Rabies (Palik, Moss) 153

Patient-physician relationship, the, by T. A. Watters 122

Pediatric gynecology, some problems of, by B. Bernard Weinstein 495

Pelvic inflammatory diseases, by William H. Bendel 248

Pelvimetry, roentgen, the role of in the management of pelvic contraction, by E. L. King 302

Phlebothrombosis, aseptic antenatal, by Melvin D. Steiner 385

Pierce, Hazel — Care of the premature infant at Charity Hospital (Pierce, Sako) 163

Pizzolato, Philip — The blood supply of the sternum i 71

Pneumoperitoneum in the treatment of pulmonary tuberculosis, by B. M. Stuart, R. L. Pullen,

J. L. Wilson 61

Poisoning, food, by George H. Hauser 362

Poliomyelitis, clinical evaluation of an intradermal test for, by Carlos Ramirez 58

Postwar problems in medical education, some, by Lewis H. Weed 43

Prenatal care, special aspects of, by Walter E. Levy 521

Proptosis, monocular, sinus disease producing, by Lucian W. Alexander 351

Prostatic obstruction and some of its complications, by Edgar Burns 243

Psychosomatic, medicine, what makes, by Sam Nelken 319

Pullen, R. L. — (Joint author), see Stuart, B. M 61

Pullen, R. L.— Rocky Mountain spotted fever (Pullen, Sodeman, Felknor) 359

— R —

Rabies, by Emil E. Palik and Emma S. Moss 153

Rackley, G. D. — (Joint author), see Romagosa, Jerome 180

Ramirez, Carlos — Clinical evaluation of an intradermal test for poliomyelitis 58

Rickettsia diseases: yellow fever; dengue and sandfly fever, by L. Everard Napier 108

Rocky Mountain spotted fever, by R. L. Pullen, W. A. Sodeman, and George Felknor 359

Roentgen pelvimetry in the management of pelvic contraction, the role of, by E. L. King 302

Rollings, H. E. — Comparison of incidence and treatment of meningitis over a ten year period

(Rollings, Musser) 445

Romagosa, Jerome — Orbital cellulitis with severe cerebral symptoms (Romagosa, Rackley) 276

— S—

Sako, Wallace — (Joint author), see Pierce, Hazel 163

Saunders, Maridel — Diagnosis and treatment of some common medical emergencies 531

Scars and keloids, production and treatment of, by Wallace Marshall 15

Schistomiasis and filariasis, by Ernest Carroll Faust 115

Schmidt, Harry J. — General considerations of brucellosis 256

Senekjie, Harry A. — Hemoflagellate infections 112

Shpiner, Leonard B. — Status endocrinologicus 205

Silverman, Daniel N. — Atypical amebic colitis (Silverman, Leslie) 435

Sinus disease producing monocular proptosis, by Lucian W. Alexander 351

Sloan, Jr., Wyman P. — Pathogenesis of hypertension 457

Socialized medicine and the doctor, by Waldemar R. Metz 151

Sodeman, W. A. — (Joint author), see Pullen, R. L 359

Sodeman, W. A. — The causes of syncope with special reference to the heart (Sodeman,

Engelhardt) 307

Steiner, Melvin D. — Aseptic antenatal thrombophebitis (phlebothrombosis) 385

Sternum, the blood supply of the, by Philip Pizzolato 71

Stewart, Chester A. — The evolution of tuberculosis in the human lung 1

Stuart, B. M. — Pneumoperitoneum in the treatment of pulmonary tuberculosis (Stuart, Pullen,

Wilson) 61

Stubenbord, William D. — Recurrent malaria in military personnel 120

Index

VII

Symposium on intensive methods of treatment of early syphilis, see Billings, Terrece E.; Knight,

Harry C.; Agee, Owen F 127

Symposium on tropical medicine, see Faust, Ernest Carroll; Miller, Albert; Walker, A. J.;

D’Antoni, Joseph S.; Napier, L. Everard; Senekjie, Harry A 93

Symposium on tuberculosis, see Stewart, Chester A.; Brown, R. Alec 1

Syncope, the causes of, with special reference to the heart, by W, A. Sodeman and H. T.

Englehardt 307

Syphilis, early, symposium on intensive methods of treatment of, see Billings, Terrece E.;

Knight, Harry C.; Agee, Owen F 127

Syphilis, the combined use of fever and chemotherapy in, by Terrece E. Billings 127

Syphilis, the great masquerader, by John A. Kolmer . 335

Syphilis, the present status of the five day intensive treatment of, by Harry C. Knight 131

Syphilis, the treatment of early, by means of eight weeks’ mapharsen therapy with bismuth,

by Owen F. Agee 134

— T—

Taquino, George J. — The diagnostic and therapeutic possibilities of bronchoscopy 291

Thrombophlebitis, aseptic antenatal, by Melvin D. Steiner 385

Tropical diseases of the war areas, the distribution and epidemiology of important, by Albert

Miller 93

Tropical medicine in the United States as a result of the war, by Ernest Carroll Faust 93

Tropical medicine, symposium on, see Faust, Ernest Carroll; Miller, Albert; Walker, A. J. ;

D’Antoni, Joseph S. ; Napier, L. Everard; Senekjie, Harry A , 93

Tuberculosis in the human lung, the evolution of, by Chester A. Stewart 1

Tuberculosis, pulmonary, pneumoperitoneum in the treatment of, by B. M. Stuart, R. L. Pullen,

J. L. Wilson 61

Tuberculosis, symposium on, see Stewart, Chester A.; Brown, R. Alec 1

— U—

Ulcer, peptic: psychosomatic and medical aspects, by Robert A. Katz 262

— V—

Visual field studies, central, the value of, over the conventional type, by Shelley R. Gaines 176

Vitamins, the effect of, on the intestinal function, by L. D. Wright, Jr 400

— w—

Walker, A. J. — Malaria 98

Warren, Edgar — Certain etiologic factors concerned with headache 389

Watt, James — The diagnosis and treatment of acute diarrheal disorders 438

Watters, T. A. — The patient-physician relationship 122

Weed, Lewis H. — Some postwar problems in medical education 43

Weinstein, B. Bernard — Some problems of pediatric gynecology 495

Wilson, J. L. — Clinico-pathologic conference (Wilson, Dunlap) 552

Wilson, J. L. — (Joint author), see Stuart, B. M 61

Wright, Jr., L. D. — The effect of vitamins on the intestinal function 400

— Y—

Yellow fever subjects, the permanent presence of specific immunizing antibodies in the blood

of, by Rudolph Matas 9

UNITED STATES WAR
BONDS and STAMPS

New Orleans Medical

and

Surgical Journal

Vol. 97 JULY, 1944 No. 1

A SYMPOSIUM ON TUBERCULOSIS*

THE EVOLUTION OF TUBERCULOSIS
IN THE HUMAN LUNG

CHESTER A. STEWART, M. D.

New Orleans

The complete evolution of tuberculosis in
the lungs in characterized by two broad and
separate phases of development to which
the terms “primary phase” and “post-pri-
mary or reinfection phase” are being ap-
plied. Each of these developmental stages
of the disease displays a special series
of inter-related phenomena which usually
make their appearance in a very orderly and
stereotyped sequence. Fortunately impor-
tant orienting information relative to many
of these changes can be obtained with com-
parative ease through serial studies on liv-
ing patients.

Clinical and experimental studies have
shown that an interval of from three to
eight or more weeks elapses following an
initial infection before evidences of the
disease become manifest. During this brief
asymptomatic invasion period the migrating
tubercle bacilli focalize at multiple points
and produce a crop of primary tubercles
which attain histologic maturity in the
course of a few weeks. At the conclusion
of this incubation period the patient de-
velops a transitory fever and becomes sen-
sitive to tuberculin. In most instances no
subjective symptoms are noticed which en-
able the patient to identify the time these
changes occurred. Obviously, therefore, the
simplest and most reliable means we have
for determining the approximate date a

*Read before the Orleans Parish Medical So-
ciety, December 13, 1943.

primary infection takes place in man is
through reapplying tuberculin tests at short
intervals to persons whose initial reaction
to tuberculo-protein was negative.

As a rule x-ray examinations of recently
infected patients are entirely negative and
often remain so throughout the remainder
of the life of the patient. Occasionally evi-
dence of calcium deposits may appear on
chest films and thus the locations of some
of the primary lesions eventually become
apparent. Often, however, the positive re-
action to tuberculin constitutes the only
demonstrable evidence the patient has tu-
berculosis in its primary phase of develop-
ment. In this large group of cases the pri-
mary lesions escape visualization owing
either to their small size or to their being
obscured by other intrathoracic opacities.

The development of roentgenographically
demonstrable infiltrations occasionally ac-
companies the initial infection with tubercle
bacilli. Under these circumstances serial
x-ray studies contribute valuable informa-
tion relative to the changes that occur in
primary tuberculosis lesions in the course
of time.

Ordinarily, the shadows cast by these in-
filtrations, which represent primary tuber-
culosis in one of the early stages of its de-
velopment, remain practically unchanged in
extent and appearance for several months.
Finally, however, they begin to resolve
slowly and eventually this reparative proc-
ess results either in the complete disappear-
ance of the lesion or in its reduction to
fibrosed or calcified deposits. The changes
these infiltrations display on a large scale
doubtlessly duplicate those which occur
typically in smaller primary lesions situated
either in the lungs or in the regionally re-

2

Stewart — Symposium — Tuberculosis

lated lymph nodes. Apparently these gross
reparative changes extend throughout a
period of about two years.

During the months the primary lesions
are resolving the patient’s disease usually
causes remarkably few signs and symptoms
that reveal its presence. After the repara-
tive process has reduced the primary foci
of disease to fibrosed and calcified deposits
the primary phase of tuberculosis enters
its protracted latent stage of development
throughout which the lesions show no ap-
preciable gross changes and the patients
remain asymptomatic but retain their sen-
sitivity to tuberculin for a long period of
time. If this were the end of the story of
tuberculosis the disease would be of little
or no consequence. Unfortunately it has
its second stage of development.

Ordinarily the reinfection or post-primary
phase of tuberculosis does not make its ap-
pearance until the antecedent primary phase
of the disease has reached and remained in
its latent fibrotic or calcified stage of de-
velopment. When this complication ma-
terializes the early reinfection lesions
usually have the appearance of small infil-
trations which show a predilection for the
upper portions of the lungs. Some of these
new foci of disease may resolve either tem-
porarily or permanently. More often, how-
ever, they remain essentially unchanged for
weeks and months and then begin to en-
large. This change is commonly accom-
panied by the development of cavities and
by the appearance of symptoms of increas-
ing severity. In this manner the post-pri-
mary or reinfection phase of tuberculosis
passes through its minimal, moderately ad-
vanced and advanced stages to culminate
frequently in the death of the patient. These
progressive changes contrast with the phe-
nomena of repair displayed with remark-
able consistency by primary tuberculosis.

On recapitulation it seems to be apparent,
that instead of bursting suddenly into
flame, tuberculosis ordinarily passes rather
leisurely through two successive stages of
development as its evolution unfurls. The
incubation or pre-allergic stage of the
disease, the brief interval occupied by the

development of sensitivity to tuberculin,
and the relatively long asymptomatic period
during which primary lesions are being re-
duced to fibrosed or calcified deposits are
successive changes which combine to make
the primary phase of tuberculosis one of
many months’ duration. Nevertheless the
phenomena that characterize primary tuber-
culosis are rarely witnessed in spite of the
additional fact the disease is passing
through its primary stages of development
in numerous persons throughout all parts
of the world where tuberculosis exists. Ap-
parently the usual failure of primary tuber-
culosis to cause appreciable symptoms ex-
plains the common failure to detect a disease
whose prevalence almost equals that of
chickenpox and measles.

After making their initial appearance
the incipient lesions of reinfection pul-
monary tuberculosis usually show little or
no growth over a period of weeks and
months, but in spite of this common ten-
dency toward leisurely development, chronic
pulmonary tuberculosis has often prog-
ressed to its advanced stage of develop-
ment before it is diagnosed. Consequently
fully three fourths of the victims of tuber-
culosis fail to receive the benefits of
therapy until after they have lost their best
chance to recover from the disease. This
situation probably results chiefly from the
fact that minimal reinfection tuberculosis
causes few or no typical and conspicuous
symptoms which facilitate its detection.
Owing to these special conditions, therefore,
periodic re-examinations including repeated
x-ray studies on asymptomatic patients are
necessary for the consistent diagnosis of
incipient tuberculosis. These requirements
create a demand for a comprehensive and
early diagnosis program which provides for
the prolific use of effective diagnostic pro-
cedures whose coat is not prohibitive.

In response to this need, perhaps the
Orleans Parish Medical Society will be will-
ing to launch its own antituberc-ulosis pro-
gram and thus demonstrate that the diag-
nosis and treatment of tuberculosis does
not require further socialization of this
special field of medical practice. With this

Stewart — Symposium — Tuberculosis

3

possibility in view, I am taking the privilege
of submitting the following program for
consideration and recommend that it be re-
ferred to the members for a final vote after
it has been revised and perfected by the
Tuberculosis Committee of the Society. The
tentative program I am presenting at this
time contains the following provisions :

1. The members of the society will ap-
ply tuberculin tests routinely to all of their
private patients. In order to facilitate test-
ing the Tuberculosis Committee of New
Orleans, which derives its support from the
sale of the Christmas seal, has agreed to
deliver diluted tuberculin to doctors’ offices.
This semi-monthly service will be free to
the profession.

2. I suggest that the Parish Medical So-
ciety purchase and operate 35 millimeter
photofluorographic unit and make this step
in the examination of private patients avail-
able to all members of the society. Also
compensate member roentgenologists for
interpreting these films. With this unit
several hundred examinations can be made
daily, and owing to the low cost of 1.5 cents
per exposure, the 35 millimeter photo-
fluorographic examination provides an in-
expensive method for screening thousands
of patients annually. This aid in detecting
pulmonary lesions is superior to stetho-
scopic examination but is inferior to stand-
ard x-ray studies. Consequently the third
provision incorporated in this program is of
great importance.

3. Physicians will obtain standard x-ray
studies on all patients whose minature films
reveal abnormalities and will also under-
take other appropriate examinations needed
for diagnosis. Incidentally, these proced-
ures will increase the private practice not
only of roentgenologist but also of other
physicians.

4. In order to support this program a
nominal charge of fifty cents or one dollar
can be made for each photofluorographic
examination. With each member of this
society referring only two patients per
week for chest pictures a minimum charge
of fifty cents per examination will produce
an annual fund of more than $30,000. This
fund should make the program self support-

ing and also provide a balance which the
Society could use to finance other health
programs.

CONCLUSION

I recommend that the physicians of New
Orleans provide their private patients with
the same inexpensive diagnostic service the
indigent in our community are receiving.
If carried out thoroughly this program will
increase the frequency with which tuber-
culosis is detected before it has become
hopelessly advanced. Early diagnosis will
greatly increase the cases that are suitable
for pneumothorax, and this accomplish-
ment will materially reduce the need for
sanatorium beds. Incidentally promotion
of the early diagnosis program I have sug-
gested probably will tend to close one door
through which the socialization of medicine
may spread in the near future if we neglect
our opportunity and duty. Apparently an
enviable opportunity exists for the Orleans
Parish Medical Society to enjoy the distinc-
tion and honor of being a pioneer in devis-
ing an economical anti-tuberculosis program
which can serve as a model for other medi-
cal societies to adopt and promote.

DISCUSSION

Dr. Sydney Jacobs (New Orleans) : Dr. Stewart

has very ehallengingly laid before us a program
whereby this Society can engage in pioneering
efforts for building up an early diagnosis cam-
paign. Unqestionably, as Dr. Stewart pointed out,
there are going to be many objections to this
plan. People will see only the formidable ob-
stacles and will not see that the ultimate goal is
worth working for. I have not spoken with Dr.
Stewart about it so I do not know how much in
detail he has worked it out. This much I do
know: It is a plan worthwhile for the Society to
consider so the private practitioner may be encour-
aged to look for tuberculosis among his own pa-
tients. Many practitioners, unfortunately, do not
look among their clientele for early cases of tuber-
culosis. Many practitioners still believe tubercu-
losis exists only when there are symptoms of far
advanced disease. It is still a sad commentary to
realize even today when x-ray is so abundantly
used and laboratory facilities over used, that many
patients have tuberculosis and escape detection
until the far advanced stage is reached.

Dr. Stewart pointed out two other things. One
is that the proper interpretation of the tuberculin
test, is an excellent aid in arriving at a diagnosis
of tuberculous disease.

4

Bro w N — Symposium — Tuberculosis

The other is that tuberculosis ought to be diag-
nosed when it can be discovered by roentgenologic
methods and not by hearing rales.

Once again I wish to commend Dr. Stewart for
his excellent presentation and hope the Society
will not take his challenge lightly.

Dr. Julius Lane Wilson (New Orleans) : We
are very fortunate to have Dr. Stewart here to
talk to us on this subject as he is one of the men
in this country who has done most to work out
some of the facts presented, particularly about
primary tuberculosis and its ultimate course in the
reinfection phase. It is interesting that twenty
or twenty-five years ago we thought of tubercu-
losis as a problem that had to be met in childhood
and treated by preventoria and other methods to
protect these children from breaking down when
adults. The pediatrician has taught us a great
deal and quite properly Dr. Stewart is the man
to present these facts.

We realize, especially since we have examined
so many million young men by x-ray and watched
so many thousands of boys and girls grow up
under observation, that tuberculosis in the poten-
tially fatal form is a problem of adults, particu-
larly young adults. We can not prevent tubercu-
losis and eradicate it by merely caring for and
protecting children although that is important.
There have appeared in the past few years new
tools and methods by which we can for the first
time approach or even realize our aim of many
years to make the diagnosis of tuberculosis early.
We have new implements, — primarly the tuber-
culin test and x-ray brought down to the reach of
thousands and millions of people, — and we have for
the first time the possibility of controlling the
disease.

There is no question, as Dr. Stewart said, con-
cerning the new law in Australia, that everyone
will be x-rayed for tuberculosis. That is the chal-
lenge Dr. Stewart puts before the Society. Of
over a half million people in New Orleans, per-
haps four hundred thousand will be taken care of
by Charity Hospital, the City Department of
Health, and State Department of Health in x-ray
examination and case finding. How about the
other one hundred and fifty thousand? It is true
that they can perhaps obtain x-rays and tuberculin
tests and the diagnostic facilities necessary to make
a diagnosis but will they? Can they obtain it by
going to the State Department of Health or the
City Department of Health, or will they have it
done through a law enforced to have this diagnosis
made? Will that be to the benefit of the patient
and the benefit of the medical profession? That
is the challenge that Dr. Stewart has thrown out
to us as I see it. I think the medical profession in
this country certainly needs such challenges as this.
We must think out ways by which we can meet
the problems of changing medical practice. There
is no question it is changing, evolving, and the
medical profession needs leadership and guidance

in meeting these problems. I wish to thank Dr.
Stewart for offering this suggestion as something
concrete that we can do.

Dr. Chester A. Stewart (In closing) : I have
nothing to add.

THIRTY-FIVE MILLIMETER FLUORO-

GRAPHY IN MASS CHEST X-RAY
SURVEYS

R. ALEC BROWN, M. D.f
New Orleans

“Finding people with tuberculosis is the
primary responsibility of all agencies en-
gaged in ridding the human race of this
devastating disease. Any method making
it possible for more people to have shadows
of their lungs made by x-ray registered per-
manently on photographic film helps to
meet this responsibility and is worthy of
serious consideration. When a method ap-
pears that decreases markedly the expense
of such registration with no great loss in
diagnostic efficiency progress has been
made. Floroscopic roentgenography (fluro-
graphy) is such a method.”1

Fluorography is the procedure of photo-
graphing with a camera the image cast by
x-rays on a fluoroscopic screen. The prin-
ciple is as old as x-ray itself (1895) but only
within recent years have developments and
improvements in fluoroscopic screens, film
emulsions, and lense systems made this
photographic technic practical.

Although numerous workers have experi-
mented with fluorography through the
years, De Abreu2 of Brazil is credited with
doing the first chest survey work with 35
mm. fluorographs in 1936.

In the past three years fluorography has
really grown up, with its acceptance by the
Army, the Navy, the United States Public
Health Service, state and local health de-
partments and industry. Selective Service
alone will have taken some 14,000,000 chest
x-rays (mostly fluorographs) in processing
men and women for military service. War
industrial plants have taken added millions
of chest fluorographs through employee

tFrom the Tuberculosis Control Section, Louisi-
ana State Department of Health.

Brown — Symposium — Tuberculosis

5

surveys or as part of a pre-employment
examination.

Having had the pleasure of working with
Dr. W. Palmer Dearing (U. S. P. H. S.) in
doing some of the first 35 mm. fluorography
in this country in 1938, I can assure you
that fluorography has come a long way.

Special chemical coating of the lense sys-
tem admitting about 20 per cent more light ;
improved clear base fluorographic film;
use of a screen grid; development of a re-
mote control, motor driven camera and just
recently a photo timer have revolutionized
the work.

Two fluorographic technics are generally
employed, one taking single 4" x 5" films,
the other 35 mm. films in rolls. (A 45 mm.
film has been tried and will undoubtedly be
the compromise film after the war when
equipment conversions are possible since it
meets the objection raised to too much re-
duction in film size while retaining the roll
film features.)

At this point it should be stated that some
radiologists are hypercritical of chest fluor-
ography. They argue that the marked re-
duction in film size with its attendant loss
of detail creates too great an interpretative
error. Commander Paul V. Greedy,3 M D.,
U. S. N., reporting on the Navy’s use of 35
mm chest fluorography, answer the query,
“How small a lesion have you been able to
detect,” thus :

“Single lesions of soft quality which ap-
pear to be one quarter inch or less in di-
ameter in the 14" x 17" film are detected
by our medical officers with photographic
experience. Calcified lesions of the apparent
size of one eighth inch or smaller in the
standard size film are readily seen. Accen-
tuated broncho-vascular markings can be
followed well out toward the periphery. We
do not claim, however, that all small lesions
are always discovered. The position of the
lesion and the quality of the film are im-
portant factors in our successes and fail-
ures.”

Fluorographs should be considered an ad-
junct to big film work and not a substitute.
It is still necessary to re-take all suspicious
and positive fluorographs on a large film.

Detailed comparative readings on known
positive chests are not to be attempted on
fluorographs.

The war time scarcity of fluorographic
equipment has kept this work largely in
the hands of official agencies employing
well trained phthisiologists and radiologists.
Two of these agencies, the Navy and the
U. S. P. H. S., maintain research divisions
for constantly improving 35 mm. work, and
all can afford to add each improvement as
it is made available. Technical and inter-
pretive errors of fluorography have thus
been kept at a level probably lower than
that for average conventional film.

Many critics of fluorography completely
ignore the fact that in the final analysis
the quicker we can approach universal
periodic chest x-rays the quicker we will lay
the foundation for the eradication of pul-
monary tuberculosis. The dictum for pub-
lic health, “the greatest good for the great-
est number” argues for fluorography.

Early diagnosis of pulmonary tubercu-
losis and proper classification for its mod-
ern treatment require chest x-rays. These
were not generally available, particularly in
our rural Southern states. To meet the
need, Virginia established one of the first
state supported travelling x-ray units about
1930. By the time the Louisiana State
Board of Health entered this field (1937)
thirty-eight states were operating travelling
chest clinics.

Operating through the local health units,
chest x-rays were made on properly refer-
red chest suspects and tuberculosis contacts
who reacted positively to the Mantoux
tuberculin test. The tuberculin testing was
done well in advance of the x-ray clinic visit
and was done primarily to screen the cases
to conserve on our x-ray work.

Full medical histories were taken, con-
ventional films were made and later de-
veloped in the central office. Reporting
was in triplicate; one copy remaining in
our central file, one kept in the health unit
file and the third copy going to the refer-
ring physician. A return visit was made
by the clinician to examine the positive
cases for a check on activity and to consult

6

Brown — Symposium — Tuberculosis

with the attending physicians. Approxi-
mately 4,500 chest x-rays were made an-
nually utilizing the one trailer mounted
x-ray unit manned by two nurses.

In 1941 the State of Louisiana purchased
a 35 mm. fluorographic unit and greatly ex-
panded the tuberculosis case finding pro-
gram. The approach is still through health
units, but survey methods are generally em-
ployed. Records now consist of a very sim-
ple identification form with a coded sys-
tem of reporting the x-ray findings. All
possible chest x-ray diagnoses are listed in
columns for easy checking. A very brief
description is made of pathology. With a
built-in two carbon record the clerical work
is kept at a minimum.

Tuberculin testing as a screening process
is no longer employed because it is simpler
and actually cheaper to make a fluorograph
than to do a tuberculin test. In addition to
all tuberculosis suspects and contacts re-
ferred in by private physicians, those al-
ready attending another health unit clinic,
that is, maternity, venereal disease, are in-
vited to have their chests x-rays. Upon re-
quest from the medical director of indus-
tries, surveys are made available to indus-
try. Those in the state eleemosynary insti-
tutions are studied periodically.

All positive industrial findings are sent
by the industrial physician to the local
physicians.

Clinics are arranged in adjourning or
near-by parishes several weeks in advance.
The health unit director is responsible for
arranging the clinic groups. Since several
hundred patients can be easily x-rayed in
a single day and since a steady stream of
patients can flow through the large metro-
politan bus from the front door past the
fluorograph and out the back door, it is
usually best to have the clinic held in a large
public building to have ample waiting room
space, proper heat and space to be used for
dressing rooms. The records are made out
by typists. The patients strip to the waist
and don capes. Paper capes are being used
in many places since the cost of laundering
the capes is more than the cost of the fluoro-

graph (about 3 cents) whereas the paper
cape costs about 1.5 cent each. Stepping
into the bus the patient presents his record
and has his x-ray number assigned. The
names are recorded in a summary book
alongside the film number. The fluoro-
graph is made and the patient returns to
the dressing room. In this manner we have
taken up to 890 films in a single day be-
tween 9 :00 a. m. and 4 :00 p. m. Ordi-
narily it is difficult to bring in more than
400 patients daily to a health unit clinic.

With so few in the school age group
showing positive chest x-ray findings, we
have discouraged routine school surveys
limiting the school examinations, for the
duration at least, to the seniors. Although
the educational value might justify the ef-
fort, difficulty in replacement of equipment
demands that we concentrate on groups
most likely to give a good tuberculosis case
yield. Whereas the Selective Service re-
jects about 1.2 per cent with tuberculosis or
with chest x-ray findings suspect of tuber-
culosis, we are finding about 1 per cent of
our adult industrial group with reinfection
type tuberculosis. We have had a surpris-
ingly low percentage of positive findings in
our white colleges and not too high findings
in our negro secondary schools.

Operating with three persons in the unit;
one recording the names, one measuring the
patients, setting the machine and exposing
the films and the third positioning the pa-
tients, we have with a “ready made group”
in our state prison taking films at a rate of
eight a minute. Actually we have been able
to do only about 40,000 studies a year with
problems of patient transportation due to
delays in machine repairs and being short
handed of personnel in our health units.
The cost of 40,000 fluorographic chest
studies has not increased much over the
previous cost of x-raying 4,500 persons an-
nually with conventional film.

With a motor driven remote control cam-
era we take films in rolls of 375 exposures
each, which are developed on a special
hangar. After the films are read they can
be spliced for filing. By buying our fluoro-
graphic film in 100 foot rolls and loading

Brown — Symposium — Tuberculosis

7

our own spools the cost of the films is seven
eighths of a cent per exposure.

All developing of the films is done in the
laboratory built in the bus. Film readings
are recorded by the doctor in the central
office in the survey books and are later
transcribed and typed on the records. When
complete, two copies of the records are sent
to the local health units, one to be kept and
the other to go to the referring physician.
Retakes on large films are recommended on
all positive and suspicious fluorographs.

In addition to our travelling unit, we have
located stationary 35 mm. fluorographic
equipment in Alexandria, Baton Rouge,
Lake Charles, Monroe and Shreveport. New
Orleans, as you know, has its own unit
mounted in a trailer. In peace times we
can expect to do over 200,000 chest fluoro-
graphs a year. Periodic chest x-rays on all
persons would enable the finding of all pul-
monary tuberculosis. Properly classified,
the arrested cases could be observed, the
treatable active cases hospitalized for initia-
tion of treatment and the unbeatable far
advanced cases isolated at home or in less
inexpensive state institutions for domicili-
ary care.

To quote Dr. I. Seth Hirsch,4 Professor
of Radiology, College of Medicine, New
York University, “Fluorographic surveys
on 35mm. film fill every diagnostic require-
ment, permitting the determination of the
earliest lesions both in the lungs and the
lymph nodes. The routine and methods of
its application are simple, rapid and prac-
tical and the cost is small. The tempo and
cost are important considerations in mass
surveys.”

He concluded his paper with the follow-
ing two paragraphs.

“With the introduction of fluorography
which simplifies and materially reduces the
cost of examination it becomes possible to
think of x-ray examinations in universal
terms.

“Thus the roentgenologist takes his place
in the great social movement for human
betterment and thus roentgenology enters
its third and most important phase as one
of the great forces of preventive medicine.”

We have indeed come a long way.

REFERENCES

1. Bridge, Ezra : Case finding with fluoroscopic roent-
genography, American Rev. Tuberculosis, 42 :155, 1940.

2. DeBbreu, M. : Collective fluoroscopy, Medical and
Surgical Society of Rio De Janeiro, July 1936.

3. Greedy, Paul V. : Microphotographic examinations of
the chest at the U. S. Naval Training Station, San Diego,
California & Western Med., 59 :37, 1943.

4. Hirsch, Seth L. : The utility of fluorography, Radi-
ology, 36:1, 1941.

Dr. Julius Lane Wilson (New Orleans) : I really
did not come prepared to discuss two papers but
I can not help but say a word about photofluoro-
graphic work. As Dr. Brown pointed out, this has
revolutionized mass use of x-ray. It reminds me
of a silly story I heard the other night. An ele-
phant saw a mouse for the first time. The ele-
phant looked down at the mouse and said, “What
are you, insect or animal?” The mouse looked up
and said, “Animal.” The elephant looked down and
said “You are awful little.” The mouse said, “Yes,
but I’ve been sick.” Photofluorographic work came
in in the position of the sick mouse to the elephant
of roentgenology. The mouse is no longer sick,
with remarkable improvement and advances in the
perfection methods and technics. With the new
addition of the photoelectric timer this method be-
comes a new and distinct departure in roentgen-
ology. It will, I am sure be widely used and there
will result an increased use of the fourteen by
seventeen films which is an entirely different
method.

As I said before, I think we must learn all we
can about this method and use it not to replace
the standard methods of roentgenology but as, in
regard to tuberculosis, a case finding method.

One other point I would like to make is that
every one of these surveys uncovers a great many
other conditions, — cardiac patients and congenital
and acquired pulmonary conditions of other kinds.
There will be many benefits not only in regard to
tuberculosis being eliminated but also in finding
other conditions of which the patient may be en-
tirely unaware.

Dr. E. C. Samuels (New Orleans) : Really I have
had practically no experience with the 35 mm. film
for the examination of tuberculosis but I have been
with the Army since the inception of the Armed
Forces Induction Station which is now approxi-
mately a year and a half and we have been using
the 4x5 or 4x10 stereo since the fifteenth of Sep-
tember a year ago. With this form of examination
we have been entirely satisfied with our results
and I think the standard of the Army which they
have set for this type of examination is probably
as high as in any of the other health units or prob-
ably any other form of mass examinations. We
have approximately run — for military reasons I
can not give exact figures — well over two hundred
thousand examinations on selectees by this method
and in one year’s time, I think Coloney Swinny will
tell you, that the Surgeon General’s Department
has charged us with approximately three errors

8

Brown — Symposium — Tuberculosis

that they have been able to detect, up to the present
time. We do not know how many more at a later
date we will eventually be charged with. One was
a case that developed tuberculosis approximately
seven months after his induction and the two others
were patients that they said had lesions that should
have been detected originally at the time the man
was inducted.

We make these examinations routinely on every
man who is presented for induction in the armed
forces. We are making today approximately three
hundred examinations a day. Some days we run
below that but it will be approximately that num-
ber probably during the twenty-eight days that
induction is performed at the station. We are able
to present the final results to the selection board
within an hour and a half after the patient has
had his initial exposure. If there is any question
at all about the 4x10 film, a stereo or flat 14x17
film is made and it is perfectly marvelous the cor-
relation between the two. We have been able to
detect in the 4x10 film what we have seen in the
14x17 plate or stereo.

In regard to the number of lesions found, we
are running approximately two per cent of positive
chests in so far as tuberculosis is concerned. From
the standpoint of location it is quite interesting.
The white males from the congested wards of the
large cities are running higher than the white
males from the country. The country negro is
running much lower than the city negro. Our
highest percentage is found in the colored race in
the congested areas of our cities; either New Or-
leans or other cities this station comprises. We
have facilities at the station, if we had to do it,
to process from five to six hundred selectees a day
for this type of examination. We would have no
trouble in running a crowd such as that and being-
able to produce the final results, dry film, by two
o’clock in the afternoon with induction starting ap-
pi-oximately at nine o’clock. We have recently been
running some other work on the side at the station
on extremities with the photofluorographic method.
Of course this has been done before. I understand
Dr. Potter in Chicago is doing practically three-
quarters of his bone work now with hte fluoro-
graphic method. We have been quite successful
in extremities and upper thoracic and cervical spine
in those we have attempted in this examination.

The other part of it is the number of lesions we
turn up outside of the lung. The number of en-
larged aortas, aneurysms of the different sections
of the aorta, the very much enlarged hearts with
every form of cardiac conditions that you could pos-
sibly find in any textbook, we see in this station in
the ordinary course of our work.

The cost unquestionably is a little higher than
the 35 mm. film but we believe, and the Army
definitely believes, that the 4x10 stereo is the
method of choice. I think Colonel Swinny will
demonstrate that to you in his discussion of this

paper. We have no quarrel certainly with the 35
mm. film but we think at the induction stations
throughout the country that we can see more with
the 4x10 film.

Dr. McClanahan (New Orleans) : I have been
at the joint Army and Navy induction center since
February first of this year. The center was in
operation some time prior to that date. I must con-
fess when I first went on duty at the station I was
a little skeptical of the 4x5 films. Occasionally a
selectee would come to induction and we suspected
tuberculosis and the small film was reported nega-
tive and I would order a larger film. So far as
I know never where we ordered such a 14x17 film
was anything found that was not found on the
small film. I have had no experience with the 35
mm. film. I helped in a case-finding study in Chi-
cago. We ran in our case-finding study three and
two-tenths per cent positive in negroes. In the
Lying-In Hospital all white patients, roughly, one
per cent were positive. Perhaps the average figures
between the negroes and white there was about as
here.

One thing I have learned and have convinced
myself of in the ten months I have been at the
Army-Navy Induction Center is that these films
are reliable. No one claims quite the detail of the
14x17 film. For case-finding I am thoroughly con-
vinced it is a reliable method and worthy of adop-
tion for mass studies when undertaken by medical
societies over the Country.

Dr. John M. Whitney (New Orleans) : I would

like to point out that this Society some months
ago approved this program of taking pictures by
fluorographic methods. I would like to correct the
impression that we might be behind the times on
that.

Dr. R. Alec Brown (In Closing) : I hardly ex-
pected to present a comparative study of 35 mm.
and 4"x5" technics, otherwise I would have giv-
en more figures regarding the technics and er-
rors of the two. Such studies have been made.
In 1940 the U. S. Navy approved 35 mm. work.
This was the first official acceptance of the tech-
niques in this country. We were delighted that
both the Army and the Navy adopted fluorographs
for their chest X-ray survey work. The Army de-
siring to keep the individual fluorograph with the
individual’s Army medical record so that a dis-
charge film could be compared with the induction
film; naturally chose the 4"x5" film.

Those of us in public health work examining
thousands of people, find the 35 mm. roll film far
more practical and more economical.

As brought out by Dr. Wilson cardiac, aortic
and other chest pathological findings add a strong
argument for the use of inexpensive routine chest
fluorographs as part of every general physical
examination.

Stereoscopic films are desirable but the added
cost of materials and wear on equipment does not

Matas — Yellow Fever Antibodies

9

justify our using this method routinely as the
Army does.

It is interesting to note in passing that 35 mm.
fluorographs are well enough accepted that they
are now being used by industry in X-raying the
aluminum castings used in our bombers and fighter
planes. The unit for doing this work was made
available for the first time this month.

THE PERMANENT PRESENCE OF SPE-
CIFIC IMMUNIZING ANTIBODIES
IN THE BLOOD OF YELLOW
FEVER SUBJECTS

EXPERIMENTALLY DEMONSTRATED BY THE
“MOUSE PROTECTION TEST”, SEVENTY-

SEVEN YEARS AFTER A CLINICALLY
RECOGNIZED ATTACK OF
THE DISEASE*

RUDOLPH MATAS, M. D.

New Orleans

In a preceding article, I described my per-
sonal experience with yellow fever — an ex-
perience which was unusual in many ways,
but especially because it seemed to challenge
the old, well-founded and generally accepted
belief that one attack of yellow fever con-
ferred permanent immunity against all fu-
ture attacks.

As previously related, and contrary to all
precedent, I had to my credit, or discredit,
the record of four distinct attacks of a fever
(contracted in the course of as many typical
and historic epidemics) which competent
experts had diagnosed as yellow fever.

Merely to recall the essential facts of the
previous discussion, I will state that the
first attack occurred in my childhood, when
seven years old, during the malignant epi-
demic of yellow fever which swept over
New Orleans and the Gulf states in 1867,
leaving 3,100 dead victims in its path. In
this, as in subsequent attacks, I was at-
tended by an able and experienced prac-
titioner who declared that my fever was of
the severe but uncomplicated epidemic type
of the then prevailing yellow fever. This
opinion was shared by my parents, who
hailed my recovery with great satisfaction

*A supplementary note to a paper on “Personal
Experience and Reflections on Yellow Fever” pub-
lished in the New Orleans M. & S. J., 96:10, 1943.

as it conferred upon me the title of “im-
mune,” which was of such inestimable value
to its possessor, and especially to doctors,
whose usefulness in all yellow fever coun-
tries depended largely upon this qualifica-
tion.

The succeeding three attacks were con-
nected with dramatic episodes which
seemed to contradict the belief in my im-
munity, as established by my early experi-
ence in the epidemic of 1867. For it was
while serving as an undergraduate intern
at the Charity Hospital of New Orleans
during the devastating epidemic of 1878;
later as laboratory assistant to the first
yellow fever commission sent by the United
States Government to Havana in 1879; and,
again in 1882, as relief physician at
Brownsville, Texas, in the widespread epi-
demic that prevailed that year in the Rio
Grande Valley — that I contracted in each
instance, a mild type of fever which my
attending physician labelled as “mild abor-
tive” or “attenuated” attacks of yellow
fever of the mild type prevailing in the
epidemics at that time. It is notable that I
recovered promptly without complications
from all these attacks. In this way, my im-
munity to yellow fever had been seemingly
quadrupled within a period of fifteen
youthful years.

I again came in frequent contact with
yellow fever in New Orleans and neighbor-
ing towns in the course of 23 years that
stretched from the epidemic of 1882 on the
Rio Grande, to the last and epochal anti-
mosquito campaign in New Orleans of 1905,
which ended in the complete extinction of
the yellow plague in New Orleans and in
the whole North American continent. Dur-
ing that period and since, I have had no
reason to fear a break in the continuity of
my immunity which, despite my great re-
spect for the opinion of the distinguished
colleagues and friends (who believed that I
had been attacked by yellow fever no less
than four different times) I have always
felt a deep conviction that it was the first
attack in my early childhood during the
epidemic of 1867—77 years ago — which
was the primitive and real yellow fever in-

10

Matas — Yellow Fever Antibodies

fection ; the attack that stamped on me the
signature which subsequently carried me
safely through the other abortive or simu-
lated yellow fever attacks.

During the nearly four decades that have
followed the great sanitary victory of 1905
in New Orleans, Yellow Jack has given no
sign of resurgence, and the horrors of his
rule have been so completely submerged
under the great wave of prosperity that
followed his extinction, that the present
generation knows the evil story of the
“Yellow Ogre of the Tropics” only as a leg-
endary tradition.

It is only since the prodigious develop-
ment of aerial ways of communication and
transportation with the newly recognized
widespread foci of infection in the jungle
areas of South America and Africa, that
memories of the old yellow fever visitations
are being revived as the sanitary authori-
ties are becoming quite alert to the dangers
of possible importation and recurrence of
the deadly pestilence in its old familiar
Southern haunts.

The discoveries and advances that have
followed in the wake of the great yellow
fever investigators and explorers of the
Rockefeller Foundation in South America
and Africa in the last two decades have so
profoundly affected and changed the previ-
ous concepts of the disease, that the early
pioneers of the beginning of the century —
Finlay, Reed and Gorgas — whose genius
opened and blazed the way to the present
advances, would scarcely recognize the old
picture of yellow fever in its new dress and
strange physiognomy.

The story of the jungle type of yellow
fever, of its vast and unsuspected Brazilian
and African habitats, of its new animal
carriers and insect vectors, and of the new
methods of detecting the presence or ab-
sence of the yellow fever virus in suspected
individuals and communities, of the meth-
ods of definitely determining the diagnosis
of active, present or past, yellow fever in-
fections, and the discovery of an infallible
test of its presence in the liver tissues after
death; and the still greater discovery of a
safe and practical vaccine for the protection

of the individuals exposed to the infection
— have all been sufficiently stressed in my
previous communication and in the vast
literature that is steadily accumulating on
this vital subject; more especially since the
prophylactic needs of our expeditionary
forces in tropical regions have added a new
spur to research in this direction.

sjs ❖ * * #

My present purpose is chiefly to avail
myself of the unusual opportunity offered
by my own, rather unique, personal experi-
ence, to determine the fact that an individ-
ual is or has been the subject of the yellow
fever infection, and to determine the im-
munity conferred by such an infection, as
well as its resistence and duration after an
attack. Having been praised for surviving
four attacks of yellow fever, it would have
been interesting to determine which one, or
if all four attacks were yellow fever; but
an answer to such an inquiry could only
have been possible at the time when the
attacks occurred. However, the fact that
the first well authenticated attack had oc-
curred in my childhood, 77 years ago, and
the last of the alleged attacks 65 years ago,
made me curious to know if my blood re-
tained any immunizing properties, despite
the unusually long period of time that in-
tervened between the original infection and
the test.

In this connection I was also interested
in knowing if there was ; ( 1 ) any clear re-
lation between the titer of the antibodies
in the serum and their protective value ;
(2) if age had any deteriorating effect on
the protecting value of the antibodies?

Very fortunately, a ready and highly au-
thorized reply to these questions was ob-
tained through the courtesy of Dr. Simon
Flexner (Emeritus Director of the Rocke-
feller Institute), Dr. J. Bauer (Director of
Laboratories) and Dr. Max Theiler (asso-
ciate) in the International Health Division
of the Rockefeller Institute for Medical Re-
search of New York, to whom I individually
and collectively wish to express my thanks
and grateful appreciation. I am particu-
larly obliged to Bauer, for his valuable
discussion of the subject in the letters here-

Matas — Yellow Fever Antibodies

11

with appended, and to Theiler for his
detailed description of the “mouse protec-
tion test,” which he applied to the speci-
men of my serum which was mailed to the
Rockefeller laboratories with all the neces-
sary precautions, through the courtesy of
Dr. Edwin H. Lawson, of the Laboratory
of Clinical Medicine of Tulane University.
Though the “mouse protection test,” which
Theiler was the first to devise and apply
by the intracerebral method, has been de-
scribed in many publications and the Index
Medicus is crowded with references to its
application by yellow fever workers all over
the world, a clear, concise description of
the technic adopted by Theiler will be ap-
preciated by all those interested in the out-
come of this notable experiment.

As the opinions of Bauer and Theiler are
strictly pertinent to this discussion, I will
quote them in the original text of their let-
ters to me.

Dr. Bauer, on June 29, 19 US, wrote: “I
have read with a great deal of interest the
proof of your paper in the New Orleans
Medical and Surgical Journal, in which you
describe your experience during the four
attacks of yellow fever. If you will arrange
to send us about 5 c.c. of your serum taken
aseptically, we shall be very glad to do a
yellow fever protection test on this speci-
men with a view to determining whether
or not you have yellow fever immune sub-
stances in your serum.

“If the test is positive, it will not allow
us to determine which of the four illnesses
was yellow fever. We do not believe that
all four attacks, which were diagnosed by
the attending physicians as yellow fever,
actually were this infection, as such an oc-
currence would not be in accord with pres-
ent-day knowledge of yellow fever. As you
well know, there are many statements in
the literature to the effect that one attack
confers lifelong immunity. It is impossible
to state whether this is true. We do not
know of a single case where a proven sec-
ond attack followed an original one, re-
gardless of the time interval. In the lab-
oratory it is impossible to reinfect an im-

mune man or monkey regardless of the
amount of highly virulent material given.

“There is a tendency during an epidemic
of yellow fever to diagnose any febrile ill-
ness, most often malaria, as yellow fever,
chiefly because there is nothing character-
istic about a mild attack of yellow fever to
aid in diagnosis. Bleeding gums and so-
called black vomit are usually absent in
malaria as well as in yellow fever. Newer
methods, such as searching for malarial
parasites under a microscope or the finding
of albumen in the urine, which is the most
diagnostic sign of yellow fever, along with
leukopenia, were not in common practice
when your attacks occurred in 1867, 1878,
1879 and 1882.

“I am willing to share your belief that
if you had yellow fever, your attack must
have occurred in 1867, and the subsequent
attacks, each of which you remember more
clearly, must have been something else. At
any rate, if you will be kind enough to send
us a sample of your serum, we shall be very
happy to determine whether or not you are,
at present, immune to yellow fever.”
(Signed) J. H.- Bauer, M. D., Director of
Laboratories.

On August 30, 19 U3, Dr. Max Theiler
wrote as follows’. “The method used for
testing your serum for antibodies against
yellow fever was the intracerebral mouse
'protection test. (Theiler, M., Ann. Trop.
Med. & Parasit., ,27:57, 1933; Baugher,
J. C. Am. J. Trop. Med., 20:809, 1940.) In
brief, the test consists of mixing the serum
to be tested with yellow fever virus of the
French neurotropic strain. The dilution of
virus added to the serum is standardized so
that mice inoculated intracerebrally with
0.30 c.c. receive approximately 100 M. L. D.
(minimum lethal dose) . As a rule six mice
are inoculated. If all or all but one of the
mice live, the result is interpreted as pro-
tection. If, on the other hand, all the mice
die, the serum is considered negative.

“In the test in which your serum was
tested titration of the virus used showed
that each mouse inoculated with a serum-
virus mixture received 50 M. L. D. Of 12
mice inoculated with the mixture contain-

12

Matas — Yellow Fever Antibodies

ing your serum 11 lived, whereas none of
the 12 mice lived which were inoculated
with a mixture of the virus and a known
normal human serum. In a similar manner
11 of 12 mice lived which were inoculated
with a mixture containing the virus and a
known yellow fever immune serum.

“I would like to emphasize that the intra-
cerebral protection test is used only by a
few workers. The standard test in exten-
sive use for several years is that known as
the intrap eritoneal protection test. (Saw-
yer, W. A., and Lloyd, W., J. Exp. Med.,
54:533, 1931.)

“It is my opinion that the titer of an
immune serum as measured by the protec-
tion test in mice gives a good indication of
the ‘protective’ value as tested in monkeys;
that is, the higher the titer, the less serum
is necessary to protect a monkey against an
experimental infection.

“As to your question whether age has any
deteriorating effect on the titer, no very
extensive observations are available. How-
ever, it is my opinion that individuals who
have had yellow fever many years ago are
not as likely to have as high a titer, as
those who have had an attack recently.”
(Signed) Max Theiler, M. D.

*****

Since the above was written, my atten-
tion has been directed by Bauer to an ex-
perimental study on the “Persistence of
Yellow Fever Immunity” by Wilbur A.
Sawyer, the present Director of the Inter-
national Health Division of the Rockefeller
Foundation (J. Preventive M., Nov. 1931,
413-418). The conclusions of this funda-
mental report, published nearly 14 years
ago, are based on the experimental test, in
monkeys, of the protecting value of the
blood serums of sixty persons who gave a
history of yellow fever attacks varying
from 30 to 78 years before the test was ap-
plied. The test applied by Sawyer differed
from the “mouse protection test” in the fact
that Rhesus monkeys were used instead of
mice. Max Theiler’s capital discovery in
1929 of the great sensitiveness of white
mice to the yellow fever virus and his intra-
cerebral injections had not been made gen-

erally available. Sawyer revised and gave
references to various publications on the
duration of the immunity conferred by yel-
low fever that had appeared in the litera-
ture of tropical diseases before his own
investigations had appeared. These obser-
vations showed the protective influence of
human serum from individuals who had
been diagnosed as having had yellow fever
from 20 to 30 years before the protection
test on monkeys was applied, but none
after such long intervals as those reported
in Sawyer’s later tables. These tables in-
cluded the record of 60 observations of in-
dividuals whose sera had been tested by
Sawyer’s monkey protection test, with the
result that in 45 individuals, or 75 per cent,
the animals were protected and survived
the inoculation of lethal doses of the virus.
The time interval between the date of the
primary yellow fever infection and the pro-
tection test varied from 30 to 78 years with
57 years as the midpoint between the ex-
tremes :

Sawyer’s test consisted in injecting a variable
amount of the human immunizing serum (1-5 c. c.
to a kilogram of body weight) into the peritoneal
cavity of a Rhesus monkey. From four to six
hours later, the monkey was given a subcutaneous
injection of the yellow fever virus of a known
virulent strain (Asibi) in fresh defibrinated blood
taken from an infected monkey on the first day of
the fever. The volume of infected blood injected
varied from .25 c. c. to .4 c. c. The monkeys were
kept under observation for thirty days and the
rectal temperature taken twice daily. For every
group of tests there was at least one controlled
monkey that received an amount of human normal
serum equal to the largest dose of serum used in
the corresponding test. The controlled monkeys
were given the same amount of virus as the test
animals, with the result that all the controlled
animals died of yellow fever with one exception,
from four to eight and a half days after the inocu-
lation. The monkeys protected by the immunizing
serum survived though not always without show-
ing, in many, marked febrile reactions.

Most pertinent to the present inquiry is
the fact that five out of six serums from
persons who have had yellow fever 75 years
before the specimens were obtained, pro-
tected the monkeys and saved them, as did
also one specimen taken 78 years after the
yellow fever attack!

Green — Milker’s Nodule

13

This is the case of a colored woman of Thibo-
deaux, La., who contracted yellow fever when a
baby six months old, her mother having the dis-
ease at the same time. This happened at the
time of the great epidemic of 1853, the most deadly
in the history of Louisiana and perhaps of the
North American continent (7,849 deaths in a popu-
lation of 151,132 in New Orleans alone, and 100
deaths in Thibodeaux, a town of scarcely 2,000
inhabitants at that time). It was reported that
this patient was alive and active in 1931, at the
time of Sawyer’s report. The blood serum from
this subject was given special attention and tested
in monkeys and later in mice. It was found that
this woman’s serum had a protecting effect in
saving the animals even in dilutions of 1 in 8 and
was still life-saving in 1 in 16 and 1 in 32 dilutions,
but not without great febrile reactions and other
evidences of weakened but still active immune
bodies. Tried on two monkeys, the serum of this
woman when injected in amounts of 3 c. c. and
1.5 c. c. per kilogram of the animal’s body weight,
respectively, saved both animals, but not without
high febrile reactions indicative of incomplete or
partial immunity; an effect which was avoided by
injecting larger doses of protective human serum.

In general, the test of monkeys and mice
are consistent. As Bauer observes, “the
highly virulent dose of the virus was used
in testing the monkeys and the test was
therefore much more severe than in the
mouse protection test.” If the latter test
had been used, it is probable that even
larger numbers of immunes would have
been found in Sawyer’s research; but even
with Sawyer’s very severe test the sera
from the persons who had yellow fever 75
to 78 years after the attack, saved the ani-
mals inoculated with lethal doses of the
virus.

In general terms, the conclusions arrived
at in this research, in which the Rhesus
monkey was utilized, have been more than
confirmed by the “mouse protection test,”
whether by the intracerebral technic of
Theiler, or the intraperitoneal method of
Sawyer. Without entering into a discus-
sion of other interesting and debatable
phases of the immunology of yellow fever,
I may state that the conclusions arrived
at by Sawyer in 1931 hold true now as they
did then.

CONCLUSION

The belief in a permanent life-long im-
munity conferred by an attack of yellow
fever finds confirmation in all the experi-

mental evidence obtained by the protection
tests with monkeys and mice, as illustrated
by the author’s recent experience which
shows that his blood serum is protective
and life-saving to mice, 77 years after a
primary attack of yellow fever.

The certainty with which the sera of
persons convalescent from an attack of
yellow fever can be relied to protect mon-
keys, mice and other susceptible animals,
is a fact too well established by experimen-
tation and by the rapidly accumulating
evidence of vaccination of armies and whole
populations, in mass, to call for discussion.

“While there is evidence suggesting that
the concentration of antibodies in the serum
may in some cases gradually diminish until
they are no longer demonstrable by pro-
tective tests with ordinary amounts of the
immunizing serum, it does not follow that
in such cases the persons become again in-
fectible.” (Sawyer).

This observation may imply that revacci-
nations may become necessary at certain
periods to reinforce the immunizing anti-
bodies in the threat of epidemics, or in fac-
ing concentration of the virus in jungle
warfare. We may trust the experience of
the present war waged in yellow fever in-
fected countries to determine the possible
need of revaccination. In the meantime,
the discovery of the “mouse protection test”
remains one of the fundamental and most
important acquisitions of Tropical Medicine
and modern Sanitary Science. It estab-
lishes the presence or absence of yellow
fever antibodies in the blood as a definite
fact beyond conjecture, and, in this way,
eliminates the bitter and unseemly wrangles
between experts in attempting to differen-
tiate the mild and atypical cases of yellow
fever which were so often insidious pre-
cursors of epidemics in the days when clin-
ical evidence was alone available.

o

MILKER’S NODULE

MARVIN T. GREEN, M. D.

Ruston

In 1940, Becker of Duluth, Minnesota,
reported his study of four cases of milker’s
nodules, which came under his observation

14

Green — Milker’s Nodule

the previous year, and stated that he had
been unable to find in American literature
any description, or report, of a case.

He presented a complete study of this
disease, which he classified as occupational,
and stated that the cause was a virus which
may be a modification of the vaccine virus,
but more closely resembles the paravaccine
of Lipschutz.

Although this is the first description of
this disease and the first case reported in
American literature, Becker, in his descrip-
tion, stated that he was sure the condition
was not rare in this country, and that his
calling attention to it would bring forth
many cases.

In discussing this same paper, Love, of
Boston, stated that, “This condition is rela-
tively unusual,” which I interpret as mean-
ing that the condition is rare.

The only other reference in American
literature I have been able to find appeared
in October, 1941, when in “Queries and
Minor Notes,” in the Journal of the Ameri-
can Medical Association, a case of a lesion
on the hand of a young woman, who spent
her summer vacation on a farm, was dis-
cussed and a diagnosis asked for. The
editor stated that, “This question has been
referred to a surgeon and to a dermatolo-
gist.” Both ventured the opinion that the
lesion was possibly milker’s nodule, and re-
ferred to Becker’s article. In the reply, one
stated that the condition is so uncommon
that possible variations in the clinical pic-
ture may not be well recognized.

The object of this paper is not to add
further to Becker’s complete description of
the disease, but simply to dispel the con-
cept of its rarity, especially in this area of
the deep South.

As a young practitioner in 1928, I saw my
first case of milker’s nodule, when a farmer
came to me with a typical nodule on the
right forefinger, and told me that it was
caused from milking a cow. The lesion
healed completely in time and left no scar.
Since that time, we have seen these lesions
and recognized them as occupational lesions
many times.

A report of a typical and most recent
case follows:

CASE REPORT

M. H., white male, 58 years of age, a school
teacher, complained of a “growth” on the right
index finger, which he stated began as a small
nodule about three weeks ago. This was not sore
or painful but had steadily grown larger. At no
time had he been ill or had any glands enlarged in
the arm. He had been successfully vaccinated for
smallpox fifteen years ago and had been vaccinated
several times since, with no reaction.

The lesion was approximately 1 cm. in diameter,
purplish, umbilicated, and was tense so that there
was a glossy appearance. The margin was well
demarcated. There was no soreness on manipula-
tion and the function of the finger was not im-
paired.

He stated that he milked his cow and had done
so for several months. So far as he knew there
were no sores on the cow’s teats or udder.

The cause of the lesion was explained to him
and a simple dressing applied and within two weeks
it had healed completely without scar.

All cases of milker’s nodules have oc-
curred in milkers of cows and usually a
history of sore teats or udder on the cow is
obtained. The lesion is usually a single
isolated one. I have never seen more than
one lesion on a person but according to re-
ports in the literature they may be multiple
and generalized.

The nodule is very distinctive and if kept
in mind would scarcely offer any differen-
tial diagnostic problem. Undoubtedly the
infectious agent is a virus. The nature of
this virus is questionable. There appear
to be at least three concepts in this regard :

(1) It is identical with that of vaccinia;

(2) it is an attenuated or modified form
of vaccinia ; (3) it is not related to vaccinia,
but is a paravaccinia of Lipschutz.

The histologic picture is not typical, but
varies with the stage of development.

TREATMENT

I have found that the best treatment is
simply protecting the lesion. It heals com-
pletely, without scar.

REFERENCE

1. Recker, Frederick T. : Milker’s nodules, J. A. M. A.,
Uo :2140, 1040.

Marshall — Scars and Keloids

15

PRODUCTION AND TREATMENT
OF SCARS AND KELOIDS* *

WALLACE MARSHALL, M. D.

Mobile, Ala.

With the use of a particular fraction of
liver extract, which was prepared from
liver paste and processed to render it safe
for parenteral treatment, Marshall treated
25 unselected cases of acne vulgaris with
this material. In this study he found that
89 per cent of these cases showed moderate
to marked improvement.1 These findings
were checked by two qualified observers
who treated the same types of cases inde-
pendently. They obtained moderate to
marked improvement in 83 per cent of their
series, and there were no failures, in that
all patients responded to some extent to
this technic.

I was able to record three-tenths of a
degree reduction of the facial skin tempera-
ture in a normal subject who had been
given the same experimental material.
This temperature change was noted by
means of a thermocouple skin thermometer.
White, blanched-out skin areas were ob-
served where the temperature drop was
recorded. These areas of vasoconstriction
were seen in every patient who received
the experimental material. Hyperemic, in-
durated skin areas were shown to be par-
ticularly prone to this vasoconstricting
action of the material. The reaction of
blanching lasted from a few days to nearly
a week in various patients.

In another study on the pathogenesis and
treatment of keloids, Marshall and Rosen-
thal2 showed that keloids could be par-
tially contracted with the use of Marshall’s
vasoconstricting material which was ob-
tained from liver extract. The blanching
of keloids and the adjacent skin took place,
even if the keloids themselves were in-
jected directly, and this phenomenon took

*Presented at the New Orleans meeting1 (South-
ern Section) of the American Federation of Clini-
cal Research, December 3, 1943.

*Prepared by Lilly Research Laboratories, In-
dianapolis, Indiana, through the courtesy of Dr.
Teeter, Medical Director.

place, also, when the material was injected
parenterally (subcutaneously).

It was found with microscopic studies,
that keloids contain a fibrous deposit along
with much tissue fluid, so that a localized
edema was, at least partly, responsible for
the keloidal swelling. With the introduc-
tion of localized vasoconstriction, through
the use of my experimental extract, the
keloids actually were reduced in size. This
reduction was actually measured and re-
corded on photographs.

From this work it appears that the for-
mation of keloids is due to a localized ex-
travasation of tissue fluid into the neo-
plasm. The partial reduction in the size
of these growths shows that at least some
of this edema can be released through
vasoconstriction. In other words, the
phenomenon of the tissue fluid flow into
the keloid can be replaced, at least par-
tially, at this time, by the experimental
production of a localized vasoconstriction
which allows a portion of the pent-up
edema to escape from the keloid. This can
be ascertained readily, since the keloid will
pit upon pressure. This was not observed
before the injection.

From studies to date, no signs of an in-
crease of blood pressure have been noted
in the many cases which have been ob-
served. Hence, the vasoconstricting fac-
tor, which I have isolated from liver ex-
tract, seems to exert only a selective vaso-
constricting action on the skin arterioles.
The contrast between this material and all
known vasoconstrietants is obvious, since
no generalized action has been observed
when this experimental material was em-
ployed.

The relationship of vasoconstriction to
the matter of wound healing has received
some attention lately. Krieg3 has used low
temperatures (ice caps) to surgical wounds
for the control of pain. He has reported a
reduction both in the complications of
anaesthesia and/or operations. Through
the use of ice caps Krieg has caused vaso-
constriction to occur.

Since the publication of Sano and
Smith’s4 work on the study of cold com-

16

Marshall — Scars and Keloids

presses to wounds, I have employed their
technic routinely. In another article5 I
discussed this aspect on the subject of
wound healing, and found that the de-
creased blood supply (partial anoxia) pro-
duced by cold compresses, seems to en-
hance wound-healing ability.

Furthermore, the use of a roll of gauze,
which is held firmly and directly upon the
wound by tension sutures, definitely pro-
duces less tendency for the formation of
keloids. Accordingly, the compress pro-
duces a partial anoxeia through the appli-
cation of pressure from the over-lying ten-
sion sutures. I have had the opportunity
of observing this fact for years and have
noted that keloids are far less apt to occur
when this method is used than when the
abdominal dressings are held in place
merely through the use of loose adhesive
tape. Here again, is the production of
vasoconstriction through the employment
of pressure dressings.

In still another study, I have observed
the healing of burns with the pressure
method as advocated by Allen,6 and in other
and in later papers by Koch and his asso-
ciates at Northwestern University Medical
School. In a recent article I7 have de-
scribed the use of an ointment* which
would not adhere to the burned areas when
the above pressure method of Allen, et al.
was employed. Even though keloids are
common in the negro, I have experienced no
keloidal formation in these burn cases
which I have treated by this method, and
the reason for this result may lie in the
knowledge that keloids are more apt to
occur if the tissue edema, which is plenti-
ful in burn wounds, is prevented from be-
coming localized. Once this takes place,
the fibroblasts begin to lay down connec-
tive tissue, and the keloid begins to develop.
Therefore, it has been my rule to compress
the wound (burn) tightly in order to pre-
vent the tissue transudate from entering
the injured area. Since the skin normally
exhibits tissue spaces which can easily be-
come accessible to the edema, pressure on
the wound wall collapse these areas.

•Modified Allantomide ointment manufactured by the
National Drug Company of Philadelphia, Pennsylvania.

Skin grafting involves the same tech-
nical points which have been discussed
above. Tissue edema is likely to be pro-
duced due to the surgical trauma, and the
formation of hypertrophic scars and keloids
may result from such a routine.

The question arose, just recently, as to
whether or not the production of vasocon-
striction could at least partially collapse
such scars which resulted from plastic sur-
gery, particularly from the use of tissue
grafts in an old burn case. A well-de-
veloped and otherwise healthy female, aged
35, suffered severe, disfiguring burns of
the face in 1930. Multiple skin grafts were
made on the burned areas with apparently
successful “takes” by a competent surgeon.
However, some hypertrophic scars devel-
oped. These improved somewhat under my
therapy, in that the skin borders appeared
to become better integrated and less pro-
nounced. The patient received one half of
one cubic centimeter of the vasoconstrict-
ing material for twenty doses which were
given twice a week. The treatments were
terminated in order to determine just how
long the improvement would remain. Prob-
ably the most severe critics’ reaction would
be from the patient herself. She stated
that the improvement persisted for two
weeks. My opinion, and that of others, is
that improvement is still present. How-
ever, the main point in question has been
settled, and that is the chronic tissue
edema, which may be present in these old
plastic surgery scars, seems to respond in
a manner as is noted when keloids and
acne scars are treated similarly. However,
the older the scar, the slighter the improve-
ment, or tendency for reversibility of tis-
sue edema, which is apt to ensue with the
use of this vasoconstricting material. This
is borne out by the statement given by this
patient who noted that the older skin trans-
plants did not hold their improvement as
well as did a skin transplant of two years’
duration. This is due, probably, to the
fact that more fibrosis (laying down of
connective tissue) has taken place in the
older transplants. Hence, vasoconstriction
is less likely partially to collapse them.

Cannon — Food: Facts and Fads

17

This observation has been noted, also, in
the previous study on keloidal growths.2

SUMMARY

An experimental liver extract fraction,
obtained by me, was given parenterally to
patients with acne vulgaris. These patients
exhibited multiple scars from the disease.
Further studies revealed that improvement
was produced by vasoconstricting material
derived from liver extract, which exerted
its pharmacologic effect on the arterioles of
the skin in normal and in scarred patients.
Shrinkage in the size of keloids was ob-
served also, because of the escape of the
transudate which was present in these
neoplasms.

The effect of vasoconstriction in wound
healing seems to be rather important, since
other vasoconstricting agents, such as the
application of cold compresses and also
pressure, seem to exert a decidedly bene-
ficial effect. Furthermore, there seems to
be less tendency to the formation of keloids
under this regime which produces a partial
tissue anoxia. The same observations held
true in the modified pressure treatment of
burns which were studied by Marshall and
Greenfield. From the information ob-
tained in the skin grafting of patient who
submitted to multiple operations, it was
found that younger grafts responded better
to vasoconstriction than did the older
grafts. Continued pressure on all skin
grafts may prevent, at least partially, scar
or keloidal formation. Plastic surgeons are
invited to observe these suggestions with
the hope that this additional information
may bring their patients and them superior
results.

REFERENCES

1. Marshall, W. : Therapeutic role of experimental

liver extract fractions upon acne eruptions, abscesses, and
scars. To be published in Journal of the Alabama State
Medical Society, 13:255 (Jan.), 1944.

2. Marshall, W., and Rosenthal, S. : Pathogenesis and
experimental therapy of keloids and similar neoplasms in
relation to tissue fluid distrubanee, Am. J. Surg., 62 :348,
1943.

3. Krieg, E. G. : Control of postoperative pain, Am. J.
Surg., 57:114, 1943.

4. Sano, M. E., and Smith, L. W. : Effect of lowered
temperatures upon growth of fibroblast in vitro ; its ap-
plication to wound healing, J. Lab. & Clin. Med., 27 :460,
1942.

5. Marshall, W. : Physiological and bacteriological fac-
tors in wound healing, Western J. Surg., Obst., & Gynec.,
51 :24, 1943.

6. Allen, H. S. : Treatment of superficial injuries and
burns of hand, J. A. M. A., 116 :1370, 1941.

7. Marshall, W., and Greenfield, E. V. : A modified

non-adherent gauze pressure treatment for burns. Amer-
ican Journal of Surgery, 58:324 (Mar.), 1944.

FOOD : FACTS AND FADS*

PAUL R. CANNON, M. D.f
Chicago, III.

It may seem somewhat unusual for a
pathologist to discuss the subject, Food:
Facts and Fads. But, aside from its gas-
tronomical appeal, perhaps most of our in-
terest in food has arisen from the patho-
logic consequences of nutritional disturb-
ances. For example, without such de-
ficiency diseases as scurvy, beriberi, rickets
and pellagra, the vitamins as such would
probably not have been discovered ; with-
out the metabolic disease, diabetes, with its
impairment of sugar metabolism, insulin
would not have been found; and without
the disease, arteriosclerosis, there would
be no urgent need to investigate its rela-
tionship to cholesterol or fat metabolism.
It is not strange, therefore, that patholo-
gists should be interested in starvation as
a worldwide problem because of its path-
ologic implications with respect to a type
of nutritional deficiency characterized by
the serious depletion of all of the food con-
stituents which are normally stored in the
tissues. Emphasis will be placed in this
discussion upon the general problem of
undernutrition and its relationship to the
war and the postwar world, with particular
attention to the following three categories :

1. Facts about food as an immediate
American problem.

2. Facts about food as a worldwide prob-
lem.

3. Food fads and their relationship to
facts.

Aside from its general influence upon

*Read at the Eighth Annual Meeting of The
New Orleans Graduate Medical Assembly, March
7, 1944.

fFrom the Department of Pathology, University
of Chicago.

18

Cannon — Food: Facts and Fads

growth, food also acts, according to Mendel,
“(a) to avert loss, because of being them-
selves consumed, the constituents of the
diet for the most part avert the necessity
for the destruction of body tissues and thus
protect the latter from disintegration and
(b) to restore what has been destroyed
within the organism.” In all these pro-
cesses the proteins, carbohydrates, fats,
salts, vitamins and water are mutually
utilized. In normal nutrition these pro-
cesses function harmoniously; when they
function otherwise malnutrition or under-
nutrition result. Today, because of the
many wartime dislocations, both malnutri-
tion and undernutrition are vast world-
wide problems; in fact, the condition of
generalized starvation, with its immense
death toll, constitutes perhaps today’s out-
standing economic and medical problem.

We in America have never had a famine
comparable in any way to the famines
which are now devastating other lands.
Our own food problems thus seem small
and almost petty when contrasted with
those of war-tired Europe and Asia. Out
of our great abundance we must renounce
only a few of our many luxuries ; instead
of a dozen kinds of meat we still have a
reasonable choice of fish, of fowl and of
some meat, and there is abundant evidence
that, as a whole, we are actually better fed
now than we have been at any time in re-
cent years. This gratifying fact is due, of
course, to our large war wages and the re-
sulting increased purchasing power; in-
deed, many of our citizens are buying meat,
milk, eggs and other good protein foods in
larger quantities than they ever did before.
Nevertheless many of us are not satisfied
with our food situation and wonder what
can be done to improve it. We have enough
of the energy foods, the fats and carbohy-
drates, but, despite employment of that in-
genious device called the “meat stretcher,”
whereby larger proportions of oatmeal,
wheat flour, soybean flour, are mixed with
our sausages and meat loaves, we are still
unhappy about its limited elasticity. As
the British say, after stretching their meat
almost to the snapping point, “We still have

but two kinds of bread, bread and sausage.”
Our approaching meat scarcity arises from
the current shortage of high protein and
other animal foodstuffs; in fact, there will
undoubtedly be a large deficit this year,
necessitating a sharp reduction in our live-
stock population. No one in this country,
unless he be a vegetarian or a Hitlerite,
relishes the prospect of a decreased meat
supply, but no type of meat stretcher can
close the gap between the 124 pounds per
capita of meat available in 1943 and the
160 or more pounds per capita desired to-
day. To be sure we may soften the un-
pleasant fact somewhat by disparaging the
use of animal protein through resurrection
of the old vegetarian argument that it is
wasteful to feed foods to animals rather
than to consume them directly. It should
not be overlooked, however, that in such a
trade the animals get the better bargain in
that they eat the whole grain, whereas we
get mainly the degerminated wheat and
corn.

But even if we have to modify some of
our former meat-eating habits, famine in
America will remain a long way off. Ad-
mitting this year’s political need for an im-
pending “famine,” and admitting also the
high nuisance value of rationing, black
markets, subsidies, food planning and the
like, nevertheless we will probably continue
to be the best-fed nation in the world.
However, in face of the grim fact that our
young folk are fighting both the enemy and
loneliness on extended battlelines all over
the world, we can surely forget, for a while
at least, our steaks and ribroasts.

When we attempt to integrate the Amer-
ican food problem into its worldwide inter-
relationships, one of the most important
questions is: Have we really solved our
food problem just by producing food for
ourselves and a few favored friends and
allies or should we attempt to utilizfe our
great productive potentiality to accumulate
food now as an offensive war weapon and
later as a humanitarian instrument for
healing the ugly wounds of war? For
example, the collapse of Italy because of
exhaustion of her war materials, including

Cannon — Food: Facts and Fads

19

food reserves, illustrates the inevitable con-
sequences of food scarcity in a warring
country. There can be but little doubt that
anticipation of forthcoming food supplies
played no small part in the breaking of the
Italian will to fight. In fact, according to
one observer “there was only one aim for
the people, to get as much food as possible.”
Although we now have to feed many of the
Italians, that fact may suggest to the hun-
gry millions in the Balkans and elsewhere
that they, too, may get food as the Italians
already have if, in the words of Churchill,
“they are willing to work their passage
back.” For strategic reasons, therefore, it
would seem to be good policy for us to ac-
cumulate large food stocks now for use as
a weapon of offensive warfare. Perhaps
it may be impossible to produce and store
large food reserves because of limitations
imposed by other prior wartime needs ; but
certainly we cannot accumulate reserves of
food if we continue to eat now most of that
which we produce. According to Profes-
sor John Black, in his book, “Food Enough”,
“Not even now have the food planners
sensed the full probable impacts of the food
shortages facing this country and its allies
now and when reoccupation begins.” But
regardless of what we can or may wish to
do about it, of at least one fact about food
we can be sure, — relentless hunger exists
throughout the world as it probably never
has before, and it will continue to domi-
nate the daily lives of millions of miserable
people until the last wretched victim of this
war has died from his terminal infection.

As the war proceeds, therefore, starva-
tion will gradually loom up as its biggest
medical fact, and food will be its only cure.
But the fact of terminal infection as star-
vation’s final malady will also afford a
clue to the remedy as well, because these
deaths result usually from nutritional im-
pairment of the bodily machinery.

The recent reports from India’s famine
areas of mounting death rates from cholera,
malaria, dysentery and other infectious
diseases merely re-emphasize the long-
known association between famine and in-
fectious disease. This sinister relationship

is all too familiar now in all the occupied
countries of Europe, where death rates
from infectious processes are rising steadily
as the destructive forces of war expand
while the total food resources shrink.

Among the food constituents utilized for
building up resistance against infectious
microorganisms, protein plays a dominant
part. This does not mean that other dietary
elements are not important; but protein
metabolism determines the structure of
the antibody mechanism, the foundation of
the entire structure of acquired immunity;
and antibodies can be fabricated only from
protein foods. We have discovered in our
laboratory that animals fed diets presum-
ably adequate in all dietary elements except
protein cannot produce antibodies effec-
tively. These antibodies, so essential for
the successful defense against diphtheria,
smallpox, tetanus, typhoid fever, scarlet
fever and many other microbic infections,
are large protein molecules composed of a
complicated assortment of amino acids.
Unless these dietary amino acids in the
form of proteins are eaten in ample quan-
tities and in a wide variety, specific anti-
bodies can no more be synthesized than can
a brick building be erected without a suf-
ficient supply of bricks.

The recently announced plans in India
to vaccinate some 9,000,000 starving per-
sons in order to prevent further deaths
from cholera and other epidemic diseases
will fail, in all likelihood, unless, at the
same time these persons also receive ade-
quate supplies of protein-rich materials
from which to produce antibodies. Evi-
dence for this statement is furnished from
World War I, where it was observed in
vaccination of starving peoples against
typhoid fever, that not infrequently the
disease developed even within a few months
after vaccination. From a practical stand-
point, therefore, these famished people
need food with which to replete their bodily
protein stores; without it they will con-
tinue to lose their capacity to produce anti-
bodies until, finally, some ordinarily mild
type of intercurrent infection will become
terminal.

20

Cannon — Food: Facts and Fads

Under these adverse circumstances the
protein foods assume a nutritional sig-
nificance out of proportion to that accorded
them in normal times because, in severe
starvation, the proteins are indispensable
both for the reconstruction of wasted tis-
sues and for the rehabilitation of damaged
immunological mechanisms. They play an
essential part in these processes both be-
cause of their chemical composition and
especially because in proper combination
they bring to the body the eight essential
amino acids which cannot be synthesized
by it. Without their presence in the diet
or in the bodily reserves, a starving person
can neither rebuild wasted tissues nor
synthesize hormones, enzymes nor anti-
bodies normally. This fact is of paramount
importance, therefore, in the planning of
relief rations because of the necessity for
them to contain a rich assortment of all
the essential amino acids as they occur
naturally in the high quality protein foods.

FOOD FADS

The extent of food faddism in the field
of nutrition will always vary inversely with
our knowledge about food facts. A fad is
defined as “a custom, amusement or the
like, followed for a time with exaggerated
zeal.” Unfortunately, the word “fad”
usually carries with it an unfavorable con-
notation; I shall use it, however, not in an
invidious way, but more as an indication of
changing attitudes towards foods.

We have always had food fads, and we
have many of them now. Today we pur-
sue with particularly exaggerated zeal the
vogues of vitaminism and food enrichment.

Of course there is nothing faddish about
a vitamin; vitamins, indeed, are highly im-
portant and essential food constituents
which vitalize many cellular activities.
Without them in the diet in adequate
amounts deficiency disease develops. But
it is difficult to believe that vitamin de-
ficiencies have suddenly become so incipient
in so many of us that we must now spend
more than a hundred million dollars an-
nually buying vitamin pills for self-diag-
nosed ailments suggested to us by skillful
advertising. We all know the old saying in

medicine that a physician who treats him-
self has both a fool for a patient and a fool
for a doctor. And yet thousands of Ameri-
cans daily diagnose vitamin inadequacies
in themselves, their friends and neighbors,
and rush to the corner drug store for vita-
min pills. But, as A. J. Carlson has so
aptly put it, the people who need vitamins
most cannot afford to buy them and those
who can afford to buy them probably do
not need them. Nonetheless, I freely admit
that some of the most glamorous pin-up
girls on the American scene owe their zest-
ful buoyancy, according to the advertise-
ments, to the miracle of thfe vitamin-B
complex ; unfortunately, however, male
pulchritude has apparently not been so
readily attained, even after the purchase
of the entire vitaminic alphabet. The
story is told about almost any luncheon
meeting of busy executives that, as the
guests sit down, the rattling sound heard
round the room is merely made by the vita-
min pills shifting cargo under the influence
of the gravitational pull.

Vitamins should be bought and eaten in
the “protective” foods, the fruits, the green
and yellow, leafy vegetables, milk, meat
and eggs, except when there is some medi-
cal reason for their additional use. The
fact that they are harmless when eaten in
large and expensive amounts does not jus-
tify the fad itself. If one needs only three
glasses of water daily for optimal health
and happiness, the drinking of nine extra
glasses of expensive bottled water causes
additional benefit to no one but the bottler
and his associates.

A fad practiced by some, which, due to
the war, is again gaining ground, is vege-
tarianism. This is so because the vast war-
time economic dislocations are leading
steadily to lowered living standards and a
definite trentd toward direct cereal con-
sumption. Even in the United States we
are now facing the unpleasant fact that
we cannot feed enlarged livestock popula-
tions with grains suitable for human con-
sumption.

But vegetarianism as a fad has always
been practiced by various groups who, for

Cannon — Food: Facts and Fads

21

religious, esthetic or other reasons have
not wished to consume animal flesh. Sects
have arisen which have also refused even
to eat milk, cheese or eggs. Most vege-
tarians, however, are actually lacto-ovo-
vegetarians, and in milk and eggs they se-
cure high quality animal proteins. Further-
more, most modern bread, at least in nor-
mal times, contained skim milk powder,
thus fortifying it, probably unbeknownst
to the vegetarian consumer, with good ani-
mal proteins to compensate for those lost
in overmilling.

Pure vegetarianism, to be sure, has cer-
tain virtues to commend it. For example,
it avoids the dangers inherent in diseased
flesh due to parasites or bacteria, such as
trichinae, streptococci, tubercle bacilli, and
bacilli of undulant fever; furthermore, it
affords an escape for those sensitive indi-
viduals who abhor the smelly realisms of
the abattoir. It also allows a higher popu-
lation density because of greater land
economy. It is largely because of vege-
tarianism that the densely populated areas
of India and China have been possible ; and
because of over-population and the prepon-
derant dependence upon cereal foods, crop
failures have caused some of the most de-
vastating peace-time famines, with count-
less deaths by pestilence. Vegetarianism
as a practical problem thus conflicts direct-
ly with that of birth control, as the British
rulers in India know full well.

In lands where vegetarianism is optional
its faddism becomes apparent. It consti-
tutes a medical problem only because the
grains, while rich in energy value, are, on
the whole, defective qualitatively and quan-
titatively, in proteins. This is true particu-
larly of wheat, corn and rice because of
our modern milling practices which elimi-
nate important vitamins, minerals and pro-
teins. The effects of these food devalua-
tions are becoming more obvious now due
to the increasing nutritional needs brought
about by the war ; and out of the need for
correction of these dietary inadequacies has
come the “enrichment” program.

Food “enrichment” might better be
thought of as a notion than a fad. Per-

haps the term “improvement” would have
been a better choice, inasmuch as, for the
most part, the attempt has been made to re-
store to foods certain nutritional properties
lost during the process of manufacture. In-
stead of being enriched, however, some of
these foods are still not even back to par-
ity. But regardless of the name, there are
foods which, either because of natural pov-
erty or because of processing injury, can
be improved artificially by adding to them
various food constituents.

Food fortification should be more indi-
cated in foods originally deficient in cer-
tain dietary elements than in foods impov-
erished by man. Some of our manufactur-
ing practices are particularly reprehensible
in that, by the subjection of naturally good
foods to high temperatures and pressures,
they depreciate the original nutritional val-
ues. For such types of nutritional trauma
no amount of so-called enrichment can
quite atone, any more than can clean linen
substitute for a needed bath.

The most recent utilization of the idea
of food enrichment is seen in our present-
day attempts to correct the deficiencies of
cereals, particularly wheat and corn, by
adding to them certain types of vitamins
and minerals which have been discarded
during milling. We can deprecate this mill-
ing practice, but the fact remains that:
(1) most people really prefer white bread
and (2) whole grain flour quickly becomes
rancid. If these two problems could be
solved the need for flour enrichment would
disappear. Our long-time aversion to
“peasant” bread has both a psychologic and
physical basis; white bread is thought of
as clean and pure, and light bread unques-
tionably affords considerably greater diges-
tive comfort. And yet we do not prefer
white butter, and we go to a lot of trouble
now to make our oleomargarine a golden
yellow. If we could cultivate a taste for a
yellowish bread of the type now used in
England as “war bread”, made from flour
of 85 per cent extraction, more of the nu-
trient values of the wheat berry could be
attained.

Because there was not time to solve

22

Henderson — Encephalitides

these two important problems in prepara-
tion for war and for the feeding of the
many people with low purchasing power,
the movement to “enrich” flour was insti-
tuted a few years ago as a measure to im-
prove white flour. The difficulty is that
the enrichment corrects only vitamin and
mineral deficiency, whereas the protein val-
ues are as low as they were before. It
should be emphasized, however, that an im-
portant purpose of bread enrichment was
also to use flour as a “carrier” for vita-
mins already low in the over-all American
diet, and not just to put back into the flour
the food constituents lost in milling.

The “white flour problem” is not par-
ticularly serious in normal times because
bread does not need to be a complete food
and is usually supplemented with high
quality proteins. But now that flour must
serve as a basis for relief rations for starv-
ing peoples its protein inadequacy becomes
more serious. Fortunately, however, this
can be corrected without much difficulty.
Several groups of workers have shown that
white patent flour can be further enriched
by supplementation with several varieties
of high quality vegetable proteins, includ-
ing soybean flour, corn germ, peanut and
cotton seed flours. The resulting blend ef-
fectively promotes the growth of young
white rats as well as recovery of starved
animals evidencing the adverse effects of
severe protein undernutrition. Such a pro-
tein-enrichment program, therefore, should
be of great value now because of its low
cost aspects and the availability of these
vegetable proteins.

conclusion

It is obvious that many if not most of our
food fads have come into prominence be-
cause of our ignorance about food facts.
Perhaps most of our troubles in this world
are essentially man-made; certainly this is
true of the deficiency diseases. Without
our polished rice and our degerminated
wheat and corn flour there would be no
beriberi or pellagra. But whether we suf-
fer from overfeeding or underfeeding, the
resultant diseases in either case represent
nutritional problems which can be solved

only as we learn more and more about the
circumstances which engender them. In
other words, as we learn more about the
facts of food, we will gradually concern
ourselves less about its fads.

o

THE ARTHROPOD-BORNE ENCEPH-
ALITIDES OF NORTH AMERICA

J. L. HENDERSON, M. D.

Grenada, Miss.

From the time of the historical account
by Von Economo of the Viennese epidemic
of “epidemic encephalitis” much interest
has been placed in this group of diseases.

As these epidemics carry with them a
high mortality, and since it has been found
that there are so many possibilities of
transmission, it is certainly important that
the physician be acquainted with the char-
acteristics of these diseases. This is even
more important now in times of war, when,
if epidemics get started, control may be
difficult. The doctors in the service should
also keep in mind the possibility of such
epidemics in the fighting men.

It seems that little has been done to give
a very accurate classification that is work-
able. The clinical syndromes are often so
similar that classification depends mostly
on the character of the infecting virus, the
locations of the diseases, and the mode of
transmission and propagation, rather than
upon differences in the clinical findings.

Dingle has suggested the following classi-
fication :

Group I. Bacteria, protozoa, and other
parasites.

Group II. Viruses.

St. Louis encephalitis

Eastern equine encephalomyelitis

Western equine encephalomyelitis

Japanese B encephalitis

Australian X disease

Forest spring encephalitis of Russia

Lymphocytic choriomeningitis

Louping ill

Virus B

Poliomyelitis

Rabies

Henderson — Encephalitides

23

Group III. Etiology unknown, probably
virus.

Encephalitis lethargica (Von Econo-
mo’s disease)

Hammon, Reeves, and Gray have further
classified a portion of Group II into arthro-
pod-borne virus encephalitides; in which
group are included: Western and eastern
equine encephalomyelitis; St. Louis encep-
halitis; Japanese B encephalitis; Russian
fall- winter encephalitis ; Russian spring-
summer encephalitis.

A newcomer to this last group has been
just reported by Lennette and Kaprowski;
namely, Venezuelan equine encephalomye-
litis. This was reported from a laboratory
in Brazil.

Fothergill has given a classification
based on the pathologic picture in which
there are two main divisions:

I. Inflammation, the chief pathologic
process.

II. Perivascular demyelinization, the
chief pathologic process.

Probably this is the most complete clas-
sification, but for this paper, that of Dingle
and Hammon will be used.

In this paper main comment will be lim-
ited to the equine and St. Louis types of
encephalitides. Since they are all so close-
ly related in regard to the clinical picture,
and especially in regard to the transmis-
sion, one could hardly write about just one
without including the others.

The Venezuelan type is included because
of the recentness of the finding and the in-
teresting clinical picture described.

ST. LOUIS TYPE

In the late summer of 1932 at St. Louis,
38 cases of an unsual type of encephalitis
with symptoms similar to that now known
as the St. Louis type occurred, in which no
etiologic diagnosis was made. In retrospect
this was clinically identical to the St. Louis
type.

In August, September, and October of
1933, there occurred in St. Louis and Kan-
sas City an epidemic of 1000 cases of a
similar disease.

Previous to this time, for a period of

14 years, sporadic cases of encephalitis had
been noted in the St. Louis Children’s Hos-
pital, which had a seasonal variation with
the peak in July and August. It is thought
that these cases may have been of the St.
Louis type.

In the same year of the first recognized
epidemic (1933), much work was done on
the etiology and epidemiology. Webster
and Wright succeeded in isolating a virus
pathogenic for mice from fatal human cases
of the epidemic, and Muckenfuss et al. did
likewise for the rhesus monkey. Other in-
vestigations demonstrated that the disease
was caused by a specific agent. This was
the first outbreak of an acute encephalitis
for which a specific etiologic agent was
found. A test was also devised by Webster
and Wright succeeded in isolating a virus
in which the neutralizing substances found
in the serum of convalescents and normal
people in the epidemic area could be used
to determine not only who had the disease,
(whether clinical or subclinical) , but also
the geographic distribution of the disease.

It was also recognized by the use of simi-
lar methods that the disease was not con-
fined to the St. Louis area, but was rather
widespread throughout the country. The
smaller epidemic occurred in the St. Louis
area in 1937 with an increased mortality
rate, especially in children. Confusion at
this time was likely because of the occur-
rence of so many cases of poliomyelitis.

In 1941 there occurred a widespread epi-
demic of both western equine and St. Louis
encephalitis in Washington, Arizona, New
Mexico, and Texas. The eastern type of
encephalitis was also present and repre-
sented the first cases of this type reported
since the epidemic in Massachusetts in
1938. Also in the same epidemic, patients
were noted whose sera were not neutralized
by any of the three viruses mentioned,
which suggests a new type of virus en-
cephalitis in this country.

ETIOLOGY AND EPIDEMIOLOGY

Casey and Brown, after studying the
epidemiologic features of the two St. Louis
epidemics, noted that the feature of these
epidemics were common to the mosquito-

24

Henderson — Encephalitides

borne diseases, and that the epidemic ap-
peared simultaneously in the same areas in
each of the two epidemics.

Leake, Musson, and Chope, as early as
1934, had reported that the mosquito was
the vector, or the disease was spread by
contact. The co-existence of the western
equine and St. Louis viruses in patients
have been reported in the last epidemics of
these two diseases in 1941. Both viruses
were isolated from the mosquito Culex tar-
salis, and neutralizing antibodies to both
viruses were isolated in as high as 50 per
cent of apparently healthy domestic fowls
in the areas of the epidemic. No such find-
ings were found in control animals away
from the area. Experimental inoculation
of chickens, ducks, horses, mice, monkeys,
guinea pigs, pigs, and rabbits has resulted
in the finding of the St. Louis virus in the
blood of these animals. Inoculation of
horses with this virus has resulted in in-
fection, both clinical and inapparent.

Antibodies to the St. Louis virus have
been found in the sera of normal and con-
valescent patients from encephalitis both
here in the United States and Africa.

In addition to the demonstration of
transmission by the Culex tarsalis as vec-
tor; it has also been demonstrated that
Culex pipiens Linn and Dermacentor vari-
ablis (dog tick) are capable vectors of the
disease.

There has been some evidence that trans-
mission by contact is also possible. Ac-
cording to the work of Hammon et al., there
are several animals which can be readily in-
fected by intranasal instillations of the
virus. Feeding infected mice does not
work so well, as shown by Harfood and
Branfenbrenner.

However, no attempt at isolation of
either the western or the St. Louis type
from the nasal washings and other secre-
tions of man or horses has been successful.

Hammon hypothesizes that the animals
necessary for the infecting of mosquitoes
must have the following characteristics :

1. They should be abundant.

2. They should show no apparent signs
of infections. (No epizootics have ever

been observed except in horses, which were
relatively few in number.)

3. They should have, as a result of a
small peripheral inoculation, a reasonably
large amount of virus circulating in the
peripheral blood.

4. It should theoretically be a bird, be-
cause in an area where epidemics occur
annually, the reservoir animal should be
one which does not bestow a first season’s
protection to its off-spring by maternal
transmission of antibodies, as frequently
occurs in mammals.

Experience has shown that very young
animals react with higher blood titers than
older ones, thus are better potential sources
of infection for the vector. This not only
applies to the St. Louis type, but is also ap-
plicable to the hypothetical animal reser-
voir of the equine type.

IN HORSES

Equine encephalomyelitis in horses is an
epizootic disease, occurring in the late sum-
mer and early fall, characterized by ex-
treme lethargy and occurring mainly
among pastured animals.

It has been estimated that over a million
horses and mules in the United States have
had the disease. Even though mules and
horses do not have a high economic value;
deaths due to the disease have been so
numerous that it has been necessary to
combat the disease in horses not only be-
cause of the danger to the human popula-
tion, but also because of the economic dis-
tress caused to farmers in sections visited
by the disease.

A subacute type of encephalomyelitis in
horses has been known in Europe for years,
but wras called Borna. In retrospect it is
entirely possible and probable that the dis-
ease has been present among the equine
population of the United States for years,
but has been misdiagnosed as botulism, or
some other similar disease. One such epi-
demic that might have been encephalomye-
litis occurred in Kansas and Nebraska in
1912 and 1914.

The disease as an entity did not become
definite until 1930, when Meyer, Haring,
and Howitt demonstrated a filtrable virus

Henderson — Encephalitides

25

as the pathogenic organism from the brain
of horses dead of the disease. In the fol-
lowing years the disease spread from Cali-
fornia to Arizona, Oregon, S. Dakota, Colo-
rado, and Nebraska, and other states west
of the Appalachian mountains. Later, in
1933, the disease - appeared along the At-
lantic seaboard, and when it was noticed
that this disease carried a mortality rate
twice as great as that in the western sec-
tions, a different etiological agent was sus-
pected. Ten Broeck and Merrill demon-
strated the immunologic difference of the
eastern virus from the western in that
same year. Again, in retrospect it is
thought the epidemic among horses in Mas-
sachusetts in 1872 and 1913 and 1914 was
the eastern type. In 1938 there appeared
the first real epidemic among horses of the
eastern type in Massachusetts. In 1938
and afterward, the disease moved down-
ward along the Atlantic seaboard and along
the Gulf Coast. Cases have been reported
in Alabama and Texas.

IN THE HUMAN

In 1932 Meyer reported three cases of
human encephalitis. These patients had
come in close contact with horses ill with
encephalitis and had symptoms similar to
those of the western type of today. The
pathologist’s report on the findings in the
brain of the one fatal case was that it was
an unusual type of encephalitis, resembling
those findings in the brain of horses with
equine encephalomyelitis.

Meyer also suggested that the brains of
future cases of human encephalitis be
studied to correlate the human and equine
diseases with more definite evidence. How-
ever, human cases did not appear during
the epidemic among horses until 1938.

In that year Fothergill et al. reported
the isolation of the same viruses as the
eastern equine strain from the brain of a
seven year old male, who had an abrupt
onset of high fever, general rigidity, and
coma, followed by death 24 hours later.
Several other cases were also reported, and
they were notable in that they came on
about two weeks after the peak of the dis-
ease among horses in the same general dis-

tribution and attended with about the same
high mortality. The disease was most pre-
valent among the young; only 15 per cent
were over 21, and one-quarter were under
one year.

In that same year cases due to the west-
ern strain were reported in California, N.
Dakota, Minnesota, and Saskatchewan; the
etiologic diagnosis being made by the isola-
tiop of the virus and the demonstration
of the neutralizing antibodies in the serum
of the patients. Following this, outbreaks
of increasing severity were noted in the
mid-west and far-east; and, in 1941, the
largest epidemic ever recorded occurred in
North Dakota and the surrounding terri-
tory, 1,080 cases with 96 deaths were re-
ported, and the etiologic agent was shown
to be the western strain. Since that time,
sporadic subclinical and fatal infections
have been reported in laboratory workers.

In December of 1943 Lennette and Kop-
rowski in Brazil reported eight human
cases of encephalomyelitis (Venezuelan).
These were laboratory workers. Before
this, however, two mild cases were de-
scribed occurring in laboratory workers.
Because of lack of adequate information,
it is at present impossible to determine the
existence of human infection in Venezuela,
where the disease is endemic among horses.

ETIOLOGY

The etiology of all three types of equine
encephalitides has been shown to be a fil-
trable virus of small size. Sharp, Taylor,
Beard and Beard have made electron micro-
graphic studies of the eastern and western
types. They reported that the eastern type
has an average size of approximately 40
mu. in diameter, and that it was spherical
in form, with an inner dense round or oval
region surrounded by an area of less den-
sity. They found the western strain to be
of the above general structure with an aver-
age size of 40.2 mu. They treated the virus
with calcium chloride and found the limit
of the virus to be more clearly defined with
an average diameter of 47.5 mu. They are
not sure that such treatment gives the true
cell outline.

26

Henderson — Encephalitides

Lennette and Koprowski make the obser-
vation that while the Venezuelan virus is
the most lethal of the three equine types
for the laboratory animals, it has caused no
deaths in the ten human cases thus far re-
ported; that the western type, which is
least virulent for laboratory animals, has
caused two deaths of four laboratory infec-
tions recorded, and that the eastern virus
has caused only one non-fatal laboratory
infection.

EPIDEMOLOGY

Soon after it became apparent that epi-
demics of encephalitis in horses disap-
peared with coming of winter, the possi-
bility of an insect vector of the disease was
suggested. In the Massachusetts epidemic,
it was demonstrated that several species of
aedes mosquito were capable of transmit-
ting the disease. Although the virus has
not been shown to occur naturally in this
species, the epidemiologic evidence is
strongly in favor of the insect as vector.
Mention has already been made of the isola-
tion of the St. Louis viruses from Culex
tarsalis, also the western type virus has
been isolated from the same mosquito. Oth-
er insect vectors have been indicated by
the appearance of the disease. The west-
ern strain has been isolated from naturally
infected Tricotoma sanguisga (assasin
bug) ; Dermacentor variablis (dog tick) and
has been shown capable of transmitting the
disease. The variety of host reservoirs for
the viruses has been shown to be great, and
experiments indicate that many more are
possible and probable. The eastern strain
has been isolated from the ring-necked
pheasant and the pigeon.

Leake, reporting the epidemic of the
western strain in and around North Dakota
in 1941, could find no definite connection
between the disease in horses and man, as
the disease in horses had quieted down.
However, it had been a heavy mosquito
year in that section. It occurred mainly in
male workers in rural districts. During
that epidemic Cox et al. reported the isola-
tion of the western strain virus from the
brain and spleen of a prairie chicken shot
in the area during the height of the epi-

demic. Neutralizing antibodies were found
in many people in the area as well as vari-
ous animals.

PATHOLOGY

The pathology of these diseases (equine)
is similar to that seen in animals. On gross
examination, there is severe edema and con-
gestion of the spinal cord and brain. The
convolutions were flattened.

Micro examination reveals focal areas of
nerve cell destruction, with much infiltra-
tion of polymorphonuclear leukocytes and
microglial cells. Numerous small thrombi
were noted in the blood vessels of the brain
and other parts of the body.

In the St. Louis type the pathology is
similar to the equine type with congestion
and edema of the brain and spinal cord.
Cuffing around the smaller vessels mainly
with mononuclear cells is present. Focal
accumulations of cells without relation to
the blood vessels is present. Neuronopha-
gia is also seen.

Since no deaths have been recorded from
the Venezuelan type, the pathologic picture
cannot be described.

Since the encephalitides, which are dis-
cussed in this paper, are so similar in their
clinical aspects, and because differential
diagnosis is almost impossible on this basis,
they will be discussed together in respect
to clinical manifestation.

Hammon, who has done so much work
with these diseases, has described the clini-
cal picture in infants, in adults, and in
children.

IN INFANTS

The onset is rather sudden with fever
and refusal to feed, soon followed by vomit-
ing, twitching, rigidity, stiff neck, bulging
fontanel, convulsions, and severe dehydra-
tion, with a marked strabismus occurring
at times. The temperature reaches 103° to
105°, sometimes 106° within 24 hours. It
remains at this level for 24 to 48 hours,
and usually falls to normal within two to
four days. Cyanosis is usually present
from the beginning. Convulsions and
twitching may be almost constant or spo-
radic, bilateral or unilateral. The motor
activity usually disappears with the fever,

Henderson — Encephcilitides

27

but may last longer, and the spasticity
leaves later. If the infant lives, it appears
normal within five to seven days after the
onset.

With proper treatment the mortality
rate is not high among infants, but unless
repeated lumbar punctures are done, the
sequelae become more serious.

Ten to forty per cent of cases recognized
in epidemics, in children under six months,
have shown such an outcome of the disease.
Among the sequelae which may become
manifest are: (1) Failure to develop nor-
mally; (2) spasticity; (3) small head size;
(4) overlapping sutures; (5) mental re-
tardation; (6) blindness; (7) epileptiform
seizures; (8) enlarged ventricles.

The eastern type runs a much more se-
vere course in infants, and the mortality
rate has been almost 65 per cent. Death
occurs within 24 to 48 hours of the onset.

IN ADULTS, AND CHILDREN (OVER THREE YEARS)

In this group the disease shows many
more varied forms. The onset is abrupt
with “grippe” like symptoms, headache is
one of the most frequent symptoms with
severe malaise, chilly sensations, fever,
backache, and abdominal distress. Within
24 hours the temperature may reach 101°
to 105°, depending on the severity of the
case. It is during this stage that nausea
and vomiting frequently ocuur. On the
second to fourth day, the temperature
reaches its peak and remains at this level
for 24 to 48 hours, then falls by lysis.

SIGNS AND SYMPTOMS

Those due to the encephalitis usually
appear at, or just before the peak of the
fever. The headache becomes more severe ;
mental depression is present (with slowed
motor activity and speech), which may
even become stupor, and from which the
patient is aroused with difficulty. Rigidity
of the neck and back is also seen, but al-
most never as great as is seen in the men-
ingitides. The pupils are small and re-
spond to light sluggishly. Rarely is nystag-
mus or strabismus noticed. The reflex
change is not constant. Scrotal or plan-
tar reflexes may or may not be normal.

Superficial abdominal reflexes are almost
always absent or unilateral. Sweating is
very profuse, and dehydration must be
guarded against.

During the next few days, in contrast to
the disease in the infant, the neurologic
symptoms and signs may become worse,
even though the temperature be falling.
These may also have added to them: (1)
Speech difficulties; (2) intention tremor;
(3) mild mental confusion ; (4) deeper stu-
por or coma with involuntary bowel and
urinary discharge.

In the severe cases, edema of the face is
common. Patients in this category often
remain stuporous and comatose long after
the temperature has subsided, and the con-
valescence usually takes place over a period
of months.

Instead of exhibiting the above picture,
it may be one of excitement and delirium.
Also, instead of being severe, it may be so
mild as to be only a headache, which lasts
for a short while.

Among the elderly, complications and
residuals are more common. Pneumonia
and renal insufficiency of a previously
damaged kidney are among the complica-
tions and causes of death.

Residuals, except in the elderly, are much
less common than in the infant group.
Among these are: tremor, weakness, nerv-
ousness, insomnia, mental deficiency, and
psychoses. Parkinsonism is uncommon.

The eastern type is limited mostly to
children; adults rarely being infected, but
the mortality is increased over the western
type, as one would expect.

The Venezuelan type has an onset similar
to influenza with a severe headache, that is
unrelieved by any drug and is very per-
sistent. In most cases, it was localized to
the frontal region. Body aches and pains
in the leg calves were noted; photophobia
was a common finding. There was drowsi-
ness, but the severe headache prevented
sleep in most cases, however, somnolence
was noted in one case. As yet, no sequelae
have been noted, and the disease is short
in its course as the other equine type. No
deaths have been reported.

28

Henderson — Encephalitides

DIFFERENTIAL DIAGNOSIS

Besides the three encephalitides (west-
ern, eastern equine, and St. Louis types),
there are two other encephalitides, which
cause confusion, namely Von Economo’s
encephalitis or encephalitis lethargica and
lymphocytic choriomeningitis.

In the St. Louis type most of the cases
are found in adults in late summer and
early autumn. The onset is sudden, the
course is acute, the sequelae are rare, and
the mortality rate is about 20 per cent. The
cerebrospinal fluid shows variable increase
in pressure, the white cell count varies
from 10 to 1000, with monocytes predomi-
nating. Circulating antibodies may already
be present in endemic areas with a rising
titer as the disease progresses. The pres-
ence of the specific virus can be noted in
the brain tissue, but it is questionable that
it can be found in the cerebrospinal fluid
or the blood. The protein of the cerebro-
spinal fluid may be elevated, but the sugar
is normal in these types.

In the eastern type the seasonal occur-
rence is as in the St. Louis type and west-
ern type, but it is found most often in chil-
dren, the clinical course is more severe, the
mortality rate is higher, 70 per cent, and
sequelae are much more frequent. The
cerebrospinal fluid may show the same
findings as the St. Louis type, except the
cell count is higher, 10-2000, and the poly-
mophonuclear cell is the one that predomi-
nates early in this disease ; later, the mono-
cyte becomes more numerous. The specific
virus is located as in the St. Louis type.
Circulatory antibodies are found as in the
St. Louis and western types.

The western type may be found in any
age group with the seasonal occurrence the
same as the other two. The onset is sud-
den and acute, sequelae are often seen in
children and elderly people, but are not so
common in the middle-aged group. The
mortality rate is greatest in children and
older people, being only around 5 per cent
in the young adults. Altogether, the mor-
tality rate is about 20 per cent. The cere-
brospinal fluid is similar to the other, ex-
cept the cell count is 100-1000, and as in

the eastern type, the polymophonuclear cell
is most numerous early, and the monocyte,
late in the disease. The specific virus has
been isolated from the brain tissue, the
blood, and the cerebrospinal fluid. Circu-
latory antibodies are present.

Von Economo’s type occurs mainly dur-
ing the winter months and may affect any
age group. The mortality rate is about 30
per cent. The onset is varied; it may be
sudden, gradual, or inapparent. The clini-
cal course is chronic and sequelae are fre-
quent and progressive, notable among them
being Parkinsonism. The cerebrospinal
fluid shows a count of 0-100 with the mono-
cyte predominating. No specific virus has
been isolated for it, nor have any neutraliz-
ing antibodies been found. It has been
rarely seen in this country since 1926.

Lymphocytic choriomeningitis occurs at
any time of the year in any age group. The
onset is sudden, the clinical course is acute,
sequelae are very rare, and the mortality
rate is zero. The cerebrospinal fluid may
have the specific virus present and shows
a cell count of 100-3000 with the lympho-
cytes predominating. Circulating anti-
bodies are present, and the specific virus
has also been isolated from the blood, but
not from the brain.

DIAGNOSIS

The clinical picture in the presence of an
epidemic may be the lead to the diagnosis,
but it is impossible on this basis alone. The
findings of the cerebrospinal fluid also
help, but the diagnosis is verified by sereo-
logic examination.

The most widely used is the finding of a
rising titer of specific neutralizing anti-
bodies in the blood serum. Five c. c. of
coagulated blood is taken, and the serum is
used for the tests. It is necessary to take
at least two specimens, one at the begin-
ning of the disease, and another thirty days
after. Three are better, and, in this case,
the second should be taken two weeks af-
ter the onset, and the third six weeks after
the onset. The findings of a rising titer
over the period makes the diagnosis. One
test is not sufficient because in the endemic
areas one finds very often a high titer in

Henderson — Encephalitides

29

the general population so that at least two
tests must be run to determine the titer
curve.

A complement fixation test has been de-
vised to make a more rapid diagnosis with
a fair degree of accuracy, but this does not
have much statistical evidence in its favor
at the present time.

TREATMENT

Treatment is mainly symptomatic. Con-
valescent serum, or specific artiserum, has
been tried, but the fact that it would have
to be given early in the disease makes it
impractical, unless a way of diagnosing the
condition earlier is made. Besides general
nursing care and the maintaining of fluid
balance, the most important thing to do is
prevent complications and sequelae.

In infants and children, repeated lumbar
punctures are the best means of preventing
the damage to the brain and the after ef-
fects thereof.

In adults, after the fever has subsided,
complications are the physician’s worry.
The patient must be watched to make sure
there is no urinary retention, the bowels
must be kept clear, and nasal secretions and
mucous in the mouth must be removed to
prevent aspiration, often with pneumonia.
Since the patient remains comatose so long
after the fever is down, it is not the dis-
ease itself that one has to combat, but the
above condition.

Urinary tract infections and pneumonia,
two of the most frequent causes of death
in these diseases, may be controlled by the
sulfonamides. They may even be given as
a prophylactic.

PREVENTION

While vaccination gives immunity for pe-
riods of about a year, it is only indicated
in laboratory workers, and others likely to
contract the disease. Control of the disease
in horses has been very effective by vacci-
nation; since the horse is an important
reservoir, control of the disease through
vaccination of horses is important.

Mosquito control is the most logical
method of prevention and is the one most
widely used. Personal protection against
the mosquito is also wise in endemic cases.

CONCLUSIONS AND SUMMARY

The arthropod-borne encephalitides of
North America and the late-reported Vene-
zuelan equine type have been discussed.

The confusing clinical picture plus the
high mortality rate and the probability of a
large animal reservoir makes it imperative
that more attention be given to this disease
— as to better methods of diagnosis, treat-
ment, and control.

The possibility of other types of insect-
borne encephalitides must also be remem-
bered in the differential diagnosis.

BIBLIOGRAPHY

Casals, J., and Polacio, R. : Diagnosis of epidemic enceph-
alitis by complement fixation test, Science, 94 :330, 1941.
Casey. A. E., and Brown, G. O. : Epidemic of St. Louis
encephalitis, Science, 88 :450, 1938.

Cox, H. R., Jellison, W. L., and Huges, L. E. : Isolation
of western equine encephalomyelitis virus from a naturally
infected prairie chicken, U. S. P. H. Rep., 56 :1905, 1941.

Dingle. J. H. : The encephalitides of virus etiology, New
England’.!. M„ 225:1014, 1941.'

Fothergill, L. D., Dingle, J. H., Farber, Sidney, and Con-
nerly, M. L. : Human encephalitis caused by the virus of
the eastern variety of equine encephalomyelitis, New Eng-
land J. M., 219 :411, 1938.

Fothergill, L. D. : Equine Encephalomyelitis. Harvard

School of Public Health, Symposium Volume, pps. 661-663.
Harvard University Press, 1940.

Fothergill, L. D. : Tentative Classification of Virus Dir-
eases of the Central Nervous System. Harvard School of
Public Health, Symposium Volume, pps. 617. Harvard
University Press, 1940.

Giltner, L. F„ and Shahan, M. S. : Equine Encephalitis.
Keeping Livestock Healthy, pps. 375-391. Yearbook of
Agriculture, 1942.

Hammon, W. M. : The epidemic encephalitides of North
America, Med. Clin. N. A.. 632-650, 1943.

Hammon, W. M., Reever, W. C„ Brookman, B., Izumi,
E. M„ and Guillin, C. M. : Isolation of the viruses of west-
ern equine and St. Louis encephalitis from culex tarsalis.
Science, 94 :321, 1941.

Leake, J. P. : Epidemic of infection encephalitis, U. S.
P. II. Rep., 22 :1902, 1941.

Sennelle, E. H., and Koprowski, H. : Human infection

with Venezuelan equine, encephalomyelitis virus, J. A.
M. A.. 123 :1088, 1943.

Meyer, K. F. : A summary of recent studies on equine
encephalomyelitis, Ann. Int. Med., 6 :645, 1932.

Meyer, K. F., Haring, C. M., and Howitt, B. : The etiol-
ogy of epizootic encephalomyelitis of horses in the San
Joaquin Valley, 1930, Science, 74 :227, 1932.

Sharp, D. G., Taylor, A. R., eBald, D., and Beard, J. W. :
Electron micrography of the western strain of equine en-
cephalomyelitis virus, Proc. Soc. Exper. Biol. & Med.,
51 :206, 1942.

Taylor, A. R„ Sharp, D. G., Beard, D„ and Beard, J. W. :
Electron micrography of the eastern strain of equine en-
cephalomyelitis virus, Proc. Soc. Exper. Biol. & Med.,
51 :332, 1942.

Ten Broeck. C.. and Merrill, M. H. : Transmission of

equine encephalomyelitis by mosquitoes. Am. J. Path.,
11 :847, 1935.

Webster, L. T., and Wright, F. H. : Recovery of eastern
equine encephalitis virus from brain tissue of human cases
of encephalitis in Massachusetts, Science, 88 :305, 1938.

30

Editorials

NEW ORLEANS

Medical and Surgical Journal

Established 1SUU

Published by the Louisiana State Medical Society
under the jurisdiction of the following named
Journal Committee:

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USO Tulane Avenue, New Orleans, La.

The Journal does not hold itself responsible for
statements made by any contributor.

APOLOGIA

It is with regret that we have to make
this request of our readers : Please do not
be disturbed by the fact that the Journal
is not appearing, as it has for many years,
promptly on the first of the month. On
account of the labor shortage the printers
of the Journal have only a limited staff, so
small as a matter of fact that it is at the
present time truly impossible for them to
complete printing of the Journal by the end
of each month.

The difficulty that the Journal has had
in printing has not been confined to it

alone. Even some of the very large na-
tional weeklies and monthlies have had the
same trouble ; for a time it was really very
difficult to secure copies of these large na-
tionally circularized publications. We have
been singularly fortunate up to the present
time not to have this trouble.

It so happens that the operator of the
linotype machine and the typesetter have
to do a type of work which is quite hard
on the eyes and requires meticulous obser-
vation of details. The printers do not want
to work overtime because of the eye and
nervous strain. One of the large Eastern
publishers of medical books recently told
the editor that as a matter of fact they
found that printers, if they work overtime,
were making so many mistakes and errors
that actually better results were obtained
when the question of fatique was elimi-
nated,— that the printer could accomplish
more during the usual eight hour day than
he could when he worked overtime.

It is to be hoped that the late appear-
ance of the Journal will be straightened out
sooner or later but in the meantime we ask
our readers’ indulgence and hope that they
will accept these apologies.

o

THE INDUCTION OF PRE-MEDICAL
STUDENTS

General Hershey has ruled that no longer
can boys who pass the age of eighteen be
deferred for the study of medicine, and
that boys who planned and contemplated
going into medicine will have to go into the
Army. The seriousness of the situation is
recognized by Mr. Paul McNutt, War Man-
power Commission, but General Hershey
says he has to obey the orders of the Gen-
eral Staff which is unwilling to exempt a
few thousand students which would make
possible continuing the steady flow of phy-
sicians into the ranks of medicine. It will
be impossible for medical schools to fill
their ranks with 4F’s and girls so that five
years from now the graduating classes will
be extremely small. This will cause a tre-
mendous difficulty in civilian practice, if
the war is over as we devoutly hope it will
be. One of the great difficulties will be

Editorials

31

staffing hospitals. It is almost impossible
to conceive of running a large hospital with
a very small staff of interns and residents.
The number of these men has already been
cut down considerably, but if they are re-
duced fifty or seventy-five per cent more
how under the sun will the Charity Hos-
pital and the larger private institutions
continue to give the service to civilians that
they are now giving, is a question which
causes great worry and perturbation to the
administrative officers of these institutions.

Fortunately, in Congress there are en-
lightened men who can appreciate what
will happen to the care of the civilian popu-
lation if the number of doctors is materially
reduced each year. House Bill, No. 5027,
has been introduced by Representative
Louis E. Miller of St. Louis, exempting
pre-medical and medical students, and Sen-
ator Lester Hill of Alabama is planning to
do the same in the Senate.

We are glad to report that the Chairman
of the Committee on Public Policy and
Legislation of the State Medical Society,
Dr. 0. C. Rigby of Shreveport, is active in
this matter, and he and his commmittee will
take measures to give vigorous support to
these bills in the House and Senate.

o

DERMATOPHYTOSES

Fungous infections are extremely com-
mon. It is said that one-third of the peo-
ple in this country suffer from athlete’s
foot. It is a nasty, mean and annoying mi-
nor disability which becomes of more seri-
ous moment when a man enters the Army
because often a soldier does not have the
opportunity of treating properly these der-
matophytoses which get worse and finally
may actually incapacitate a man. In a re-
cent article in the Bulletin of the United
States Army Medical Department the treat-
ment of this annoying condition was dis-
cussed and inasmuch as the civilian popu-
lation as well as the military population are
victims of this disorder, it might not be
amiss to mention a few of the admonitions

of the group of authors* who prepared this
paper.

There are certain general hygienic prin-
ciples that must be observed, such as clean-
liness by frequent washing of the feet and
frequent changing of the socks. After
washing the feet should be dried very care-
fully, particularly between the toes, but
vigorous rubbing should not be employed.
On every possible occasion permit aeration
by removing the shoes and socks and at
every opportunity elevate the feet. Strong
fungicides and antiseptics should not be
employed. Once in a while in chronic
cases with involvement of the thick stratum
corneum of the sole more vigorous treat-
ment may be necessary. For example, for
intertrigo an effective fungicidal paint is
made up with benzoic acid 5 grams, acetone
15 c. c., cotton seed oil 85 c. c. For more
obstinate cases an ointment is recommend-
ed containing salicylic acid 10 grams, pre-
cipitated sulfur 10 grams, starch powder 30
grams and petrolatum 50 grams. Whit-
field’s ointment should never be used ex-
cept in half strength. Fissured and denud-
ed cases should be painted with 5 per cent
aqueous silver nitrate. For more severe
lesions a gauze impregnated with some
bacteriostatic agent is applied as an open
dressing. Recommended is the following:
zephiran concentrate (10 per cent) 5 c. c.,
water 20 c. c., lanolin 25 c. c., petrolatum
50 c. c. Frequently 5 per cent sulfathiazole
ointment will succeed when this zephiran
ointment fails. Lesions on the plantar sur-
face of the foot require intensive treatment,
the details of which will not be given here.

After the active lesions have subsided,
hygienic measures should be followed con-
tinuously as recurrence is extremely com-
mon. Patients should be given a good
fungicidal paint to be used over the entire
surface of the toes, toenails and soles of
the feet once a week. A formula for such
paint is: tincture of iodine (7 per cent) 15

* Hopkins, J. G., et al. : Treatment and preven-
tion of dermatophytosis and related conditions,
Bull. U. S. Army Med. Dept., 77:42, 1944.

32

Organization Section

c. c., salicylic acid 3 grams, benzoic acid
6 grams, camphor 10 grams and alcohol
sufficient to make up 100 c. c. solution.

These are some of the methods for the
treatment of dermatophytoses that have
been developed by the Office of Scientific

Research of the National Research Coun-
cil and Columbia University. As they seem
to be successful in the treatment of an ex-
tremely common condition in the Army
they should prove equally effective, if not
more so, in civil life.

ORGANIZATION SECTION

The Executive Committee dedicates this page to the members of the Louisiana
State Medical Society, feeling that a proper discussion of salient issues will contri-
bute to the understanding and fortification of our Society.

An informed profession should be a wise one.

MEDICAL ACTIVITIES

It may be interesting to know that the
Executive Committee held a very important
meeting on May 27. You may, therefore,
like to learn of some of the important mat-
ters which were discussed for the benefit
of the organization. Although we did not
anticipate having a very large annual meet-
ing owing to war conditions, it was very
gratifying to report that we had a total
registration of 652. Also you may be in-
terested to know that we are only about
five per cent off of our regular member-
ship in comparison with this time last year.
Owing to the importance of medical educa-
tion and especially as a constructive plan
for postwar purposes, the president and
Executive Committee deemed it advisable
to enlarge the Committee on Medical Edu-
cation to five members instead of three. It
is desired that this committee will make a
comprehensive study of the present and fu-
ture needs for our medical institutions
incident to the war and the peace which fol-
lows it.

Many legislative bills which were pres-
ently being considered by the Legislature
were discussed. The Committees on Public
Policy and Legislation of the State Medical
Society and Orleans Parish Medical Society
were cooperating one hundred per cent to
support bills of value to the medical pro-
fession and to oppose those inimical to the
practice of medicine. The Executive Com-
mittee went on record as opposing any bills
that will lower the standards of medicine
or any of its branches in the state.

In keeping with the desire to participate

in constructive matters in relation to medi-
cine and help in constructive plans for the
future, the State Society through the presi-
dent became a participant in the newly or-
ganized Business, Trade and Agricultural
Association. They have a state council
upon which the Medical Society will be ade-
quately represented by Dr. Rhett McMahon,
president-elect, when meetings are held in
Baton Rouge, and Dr. E. L. Zander, when
meetings are held in New Orleans.

Some very constructive recommendations
of the past Arrangements Committee, Dr.
Daniel J. Murphy, Chairman, were dis-
cussed and acted upon. That arrangements
be made whereby the meetings of the New
Orleans Graduate Medical Assembly and
the Louisiana State Medical Society be far
enough apart so as not to penalize the State
Society’s convention by making it more dif-
ficult to obtain sufficient exhibitors to pay
for the expenses of the convention. Motion
was made and carried that a committee be
appointed to meet with representatives of
the New Orleans Graduate Medical Assem-
bly to adjust the question of dates, if pos-
sible. It was the opinion of the members
present that such a committee should be
composed of New Orleans men. Because of
the fact that so many of our membership
complained about contraceptive exhibits
being displayed at our meeting, it is recom-
mended that for peace and accord these
companies be left off of our exhibitors list.
When a supper dance is proposed, it is rec-
ommended in order to save money, that the
tickets to same be distributed on the day
of the supper dance so that one can estimate

Orleans Parish Medical Society

33

more closely the number of probable guests.
It is regrettable that our attendance at the
function of the Presidential Address is so
poorly attended. Therefore, in order to as-
sure a larger and more representative at-
tendance, it is suggested that this function
be joined with a smoker or some other type
of attendance producer. Motion was made
and carried that the chairman of the next
Committee on Arrangements be empowered
to arrange the meeting according to sug-
gestions of the present chairman.

The executive officers have not yet been
able to settle the time and place of the an-
nual meeting of the Society in 1945. The
final decision will be based upon the exi-
gencies of the war and whether it is desired
to have a full meeting as we had in 1944
or simply a business meeting. An appro-
priate committee has been appointed to
discuss with the New Orleans Graduate
Medical Assembly the selection of dates, in
order that our meetings will not conflict,
and unquestionably as soon as this im-
portant feature is settled more definite
information will be available as to our next
annual meeting.

Dr. C. C. deGravelles, our past president,
presented to the Executive Committee a
very interesting report of his recent trip
to Washington in regard to the Emergency
Maternal Infant Care plan. Although he
was received with open arms and listened
to with a great deal of interest the EMIC
plan was continued in force in the Chil-
dren’s Bureau and appropriations for same
increased over last year.

Our president has been very busy with
appointments of committees and taking
care of work now which has been inten-
sified as a result of the Legislature and the
numerous medical bills which had to be re-

viewed and attended to by our Committee
on Public Policy and Legislation.

You may be interested to know some-
thing about the status of medical legisla-
tion which confronted the Committees on
Public Policy and Legislation of the State
Society and Orleans Parish Medical Society
during the present session of the Legisla-
ture. Unquestionably, on account of the
number of medical bills in which the pro-
fession was interested, there developed
greater activity on the part of the members
of the committees than had been necessary
in the past. They have met these problems
successfully and to the benefit of the medi-
cal profession, giving of their time and
energy in order that the practice of medi-
cine in this state will be maintained on the
high plane as it has in the past. It was
only by this timely cooperation by the two
legislative committees that such wonderful
results were accomplished.

Owing to the fact that the Legislature
has not yet adjourned and some of these
important matters are still pending before
that body for disposition, it would be very
premature and untimely to mention any one
bill specifically. Besides, owing to the un-
usual opportunity for publicity through the
channels of our Journal it might be deroga-
tory to the best interests of the State So-
ciety to print verbatim the positions of the
committee taken on many of these bills. In
all there were over 150 bills reviewed, about
forty of which appertained to medical sub-
jects and problems. Suffice it to say that
I know the medical profession of this state
will be more than gratified to know of the
favorable results accomplished. At a later
date it might be wise to deal with specific
bills more in detail after the present ses-
sion of the Legislature.

TRANSACTIONS OF ORLEANS PARISH MEDICAL SOCIETY

CALENDAR OF MEETINGS

July 5. Clinico-pathologic Conference, Charity
Hospital Morgue Amphitheater, 1:30
p. m.

Clinico-pathologic Conference, Marine
Marine Hospital, 7:30 p. m.

July 6. Clinico-pathologic Conference, Touro In-
firmary, 11:15 a. m. to 12:15 p. m.

July 10. Scientific Meeting, Orleans Parish Medi-
cal Society, 7:30 p. m.

July 19. Clinico-pathologic Conference, Charity
Hospital Morgue Amphitheater, 1:30
p. m.

34

Louisiana State Medical SocieUj Neivs

Clinico-pathologic Conference, Marine
Hospital, 7:30 p. m.

July 20. Clinico-pathologic Conference, Touro In-
firmary, 11:15 a. m. to 12:15 p. m.

July 26. French Hospital Staff, 8 p. m.

Catholic Physicians’ Guild, 8 p. m.

July 27. Clinico-pathologic Conference, Touro In-
firmary, 11:15 a. m. to 12:15 p. m.

DePaul Sanitarium Staff, 8 p. m.

July 28. L. S. U. Faculty Club, 8 p. m.

New Orleans Hospital Dispensary for
Women and Children Staff, 8 p. m.

During the month of June the Society held one
regular scientific meeting. At this meeting the
following papers were presented: Carcinoma of the
Larynx by Dr. F. E. LeJeune; Diagnostic and
Therapeutic Value of Bronchoscopy by Dr. George
J. Taquino. Dr. L. W. Alexander opened the dis-
cussion to Dr. LeJeune’s paper; Dr. Louis A.
Monte opened the discussion to Dr. Taquino’s pa-
per. Motion pictures on Massage — Occupational
Therapy were also shown at this meeting.

Drs. Joseph A. D’Antoni, Granville A. Bennett,
and Harry A. Senekjie participated in the re-
fresher course in tropical disease held at the Tu-
lane University School of Medicine during the
week on May 15.

Speakers at the refresher postgraduate course
in pediatrics at the Tulane University School of
Medicine May 8-11 included Drs. Ralph V. Platou,
Joseph D’Antoni, William B. Clark, J. D. Russ,
Roy de la Houssaye, Guy A. Caldwell, Allan J.
Hill, Julian Graubarth, and Branch Aymond.

Among the speakers at the two-day convention
of the negro doctors, dentists and pharmacists of
Louisiana at Flint-Goodridge hospital were: Drs.
Waldemar R. Metz, M. L. Pareti, Val H. Fuchs,
and Rupert E. Arnell.

Dr. Theodore J. Dimitry was elected and has
been formally confirmed as Regent for District
No. 11 (Arkansas, Louisiana and Mississippi) of
the International College of Surgeons.

Drs. Edmund Connely, Lewis A. Golden, Walter
Otis, Randolph Unsworth, Theodore A. Watters, I
Dean Echols, and Gilbert Anderson attended the
meetings of the American Psychiatric Society in
Philadelphia and the Harvey Cushing Society and
American Neurological Society in New York in
May.

Dr. Daniel J. Murphy spoke on “The Family,
God’s Plan Fulfilled” at a meeting of the Catholic ]
Parents’ Forum at the Roosevelt Hotel, May 10.
—

Dr. Henry Ogden has been elected to the Execu- i
tive Committee of Regents of the Southwest Al- I
lergy Forum.

Drs. Urban Maes, J. D. Rives, and Lawrence
O’Neal attended the annual meetings of the Ameri- j
can Surgical Association and the American Asso-
ciation for Thoracic Surgery in Chicago during
May.

Dr. P. T. Talbot addressed the Kiwanis Club
of Amite on the Wagner-Murray Senate Bill 1161.

Dr. Gilbert C. Anderson was elected vice-presi-
dent of the Harvey Cushing Society at the annual
meeting in New York, May 18.

Dr. W. A. Sodeman has been re-elected secre-
tary-treasurer of the local chapter of Sigma Xi;
Dr. Grace Goldsmith was named to the Executive
Committee.

Dr. I. L. Robbins addressed the B’nai B’rith
Women’s Auxiliary on “Daniel Deronda.”

Dr. Julius Lane Wilson was installed as presi-
dent of the American Trudeau Society, the medi-
cal section of the National Tuberculosis Associa-
tion, at the annual meeting in Chicago, May 9-12.
Dr. Chester A. Stewart also attended the meeting.

Dr. John R. Schenken addressed the Traffic Club
of New Orleans on “Cancer and its Control.”
Daniel J. Murphy, M. D.,

Secretary.

-O

LOUISIANA STATE MEDICAL SOCIETY NEWS

CALENDAR

PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS

Society

East Baton Rouge

Morehouse

Orleans

Ouachita

Rapides

Sabine

Second District

Shreveport

Vernon

Date

Second Wednesday of every month
Second Tuesday of every month
Second Monday of every month
First Thursday of every month
First Monday of every month
First Wednesday of every month
Third Thursday of every month
First Tuesday of every month
First Thursday of every month

Place

Baton Rouge
Bastrop
New Orleans
Monroe
Alexandria

Shreveport

Louisiana State Medical Society News

35

DR. ROY B. HARRISON HONORED
A committee of 19 outstanding men have been
selected by the Advisory Council on Medical Edu-
cation to study the problems of post-war medical
training. Dr. Harrison is one of the group who
will make up this committee. He is the only mem-
ber from the South and his selection is an indica-
tion of Dr. Harrison’s national reputation as a
man of intelligence, broad-vision and an able rep-
resentative of the medical profession.

FIFTH DISTRICT MEDICAL SOCIETY
Dr. Val H. Fuchs, President of the State Medical
Society, Dr. John Menville, Dr. J. D. Rives, and
Dr. Edgar Hall, all of New Orleans, attended the
meeting of the Fifth District Medical Society in
Monroe on Thursday, June 22.

L. S. U. MEDICAL SCHOOL NOTES
The Department of Pathology and Bacteriology
of Louisiana State University School of Medicine
received the gold medal, the highest award for ex-
hibits, at the meeting of the American Society of
Clinical Pathologists in Chicago. The title of the
exhibit was The Pathology of Amebiasis, Malaria
and Histoplasmosis.

Two faculty members of the Louisiana State
University School of Medicine participated in
the medical program which was given by the
Fifth District Medical Society of Louisiana at
Monroe, Louisiana, on Thursday, June 22, at 6:30
p. m.

Dr. Edgar Hull, Director of the Department of
Medicine, spoke on The Threat of Tropical
Diseases.

Dr. James D. Rives, Clinical Professor of Sur-
gery, spoke on The Diagnosis and Treatment
of Carcinoma of the Rectum and Recto-sigmoid.

Dr. P. Jorda Kahle and Dr. R. F. Sharp, of the
Department of Urology, attended the annual
meeting of the American Urological Association
which will be held in St. Louis, Missouri, June
19-22.

After leaving the American Medical Associa-
tion meeting in Chicago, Dr. R. E. Arnell went to
Hershey, Penna., where he presented a paper on
A Therapeutic Regimen for Eclampsia: Based on
a Personally Conducted Series of 142 Consecutive
Cases Without a Maternal Fatality before the
American Gynecological Association on June 19,
1944.

At the meeting of the American College of
Chest Physicians in Chicago, Dr. C. A. Stewart,
Director of the Department of Pediatrics, pre-
sented a paper on Tuberculosis Control Programs
on June 10.

The Department of Pathology and Bacteriology
presented two papers and three exhibits at the
annual meeting of the American Society of Clini-
cal Pathologists in Chicago and the Department
of Public Health contributed one exhibit: Dr.
John R. Schenken read a paper on Disseminated
Granuloma Venereum, of which he and Dr. Emil
Palik are the authors, and Dr. E. L. Burns pre-
sented a paper on Mycetoma Pedis, which he, Dr.
Emma S. Moss, and Dr. John W. Brueck of the
Department of Pathology and Bacteriology wrote.
The exhibits are: The Pathology of Malaria; The
Pathology of Amebiasis; The Pathology of Histo-
plasmosis; and, from the Department of Public
Health, A Comparison of Strongyloides Stercoralis
with Necator Americanus by Dr. Marion Hood.

Dr. L. W. Williams of the Department of
Anatomy staff attended the annual meeting of the
Association for the Study of Internal Secretions
which was also held in Chicago, on June 12 and
13, during the American Medical Association
meeting.

CHARITY HOSPITAL

A meeting of the Medical Section of the Charity
Hospital Visiting Staff was held on Tuesday, June
20, 1944, at 8 p. m., in the auditorium. The fol-
lowing most interesting program was presented:

1. A case illustrating problems in the diagnosis
of Addison’s disease, by Dr. W. H. Gillentine.

2. Deviations in the prothrombin time in carci-
noma of the cervix, by Drs. M. Garcia and J. V.
Schlosser.

3. Case presentation by Department of Medicine
of Louisiana State University.

SOUTHERN BAPTIST HOSPITAL
The regular monthly Clinical Staff Meeting was
held on May 30, at 8 p. m., in the chapel of the
hospital. Dr. Douglas Donath, U. S. Marine Hos-
pital, on invitation of the staff, gave a motion pic-
ture demonstration of the surgical treatment of
ascites. The death report presentation was made
by Dr. W. H. Gillentine.

A meeting of the Clinical Staff was held on
June 27 at 8 p. m. in the hospital. The following-
program was presented: Stricture of the Larynx
by Dr. C. L. Cox; Hypertension of Renal Origin
in Men by Dr. W. H. Gillentine; Death Report by
Dr. Joe Wells.

AMERICAN MEDICAL ASSOCIATION
The following members of the Louisiana State
Medical Society attended the meeting of the Amer-
ican Medical Association in Chicago, June 13-16:
Drs. John Adriani, New Orleans; Ruth G. Aleman,
New Orleans; Charles Bahn, New Orleans; Wood-
ard D. Beacham, New Orleans; C. H. Binford,
New Orleans; Donovan C. Browne, New Orleans;

36

Louisiana State Medical Society News

George Burch, New Orleans; B. I. Burns, New;
Orleans; Edgar Burns, New Orleans; Guy A. Cald-
well, New Orleans; Wm. B. Clark, New Orleans;
C. Grenes Cole, New Orleans; Donovan F. Davis,
Lake Providence; B. J. DeLaureal, New Orleans;
V. J. Derbes, New Orleans; Theodore J. Dimitry,
New Orleans; Vincente D’lngianni, New Orleans;
Dean H. Echols, New Orleans; James Q. Graves,
Monroe; Roy B. Harrison, New Orleans; George
Hauser, New Orleans; Ralph H. Heeren, New Or-
leans; Arthur A. Herold, Shreveport; James K.
Howies, New Orleans; Sydney Jacobs, New Or-
leans; Barron Johns, Shreveport; C. Gordon John-
son, New Orleans; Alfred L. Lewis, Amite; Frank
L. Loria, New Orleans; John G. McClure, Welsh;
J. W. McLaurin, Baton Rouge; L. D. McLean,
New Orleans; W. R. Mathews, Shreveport; M. W.
Matthews, Shreveport; Emma S. Moss, New Or-
leans; Walter Moss, Lake Charles; John H. Mus-
ser, New Orleans; Alton Ochsner, New Orleans;
Neal Owens, New Orleans; Emile Palik, New Or-
leans; C. L. Peacock, New Orleans; Rawley M.
Penick, Jr., New Orleans; F. W. Pickell, Baton
Rouge; William H. Pierson, Natchitoches; I. L.
Robbins, New Orleans; Robert A. Robinson, New
Orleans; Wallace Sako, New Orleans; John R.
Schenken, New Orleans; Robert F. Sharp, New
Orleans; John S. Shavin, Shreveport; Daniel N.
Silverman, New Orleans; William A. Sodeman,
New Orleans; Gretchen V. Squires, New Orleans;
C. A. Stewart, New Orleans; T. B. Tooke, Jr.,
Shreveport; Herbert L. Weinberger, New Orleans;
Theodore A. Watters, New Orleans; S. George
Wolfe, Shreveport.

Louisiana physicians were well represented on
the scientific program of the American Medical
Association. The following is an account of their
activities.

The following papers were read by Louisiana
men:

“Bagasse Disease of the Lungs” (Lantern dem-
onstration), by Dr. W. A. Sodeman and Dr. R. L.
Pullen, New Orleans.

“Intractable Amebic Colitis” (Lantern demon-
stration), by Dr. D. N. Silverman and Dr. Alan
N. Leslie, New Orleans.

“The Effect of Moisture on the Absorption Ef-
fiency of Soda Lime” (Lantern demonstration), by
Dr. John Adriani, New Orleans.

“Problems in the Surgical Treatment of Con-
genital Megacolon” (Lantern demonstration), by
Dr. Rawley M. Penick, Jr., New Orleans.

“Protein Deficiencies in Pregnancy” (Lantern
demonstration), by Dr. Rupert E. Arnell, New Or-
leans and Dr. Daniel W. Goldman, Shreveport.

“The Early Immunization Against Pertussis”
(Lantern demonstration), by Dr. Wallace S. Sako
and Dr. W. L. Trueting, New Orleans; David B.
Witt, Surgeon (R), U. S. P. H. S. and S. J. Nicha-
min, Surgeon (R), U. S. P. H. S.

In addition to these papers Dr. Guy A. Caldwell
presented the chairman’s address at the Section
on Orthopedic Surgery. Dr. T. A. Watters was
vice-chairman of the Section on Nervous and
Mental Disease, and Dr. Alton Ochsner was secre-
tary of the Section on Surgery, General and Ab-
dominal.

Dr. Edgar Burns discussed a paper on “Pyelo-
cystanastomosis” and Dr. Donovan C. Browne was
listed for the discussion of the paper by Dr. J.
Arnold Bargen on “Inflammatory Lesions of the
Colon.”

There were two scientific exhibits, both from
the Department of Medicine of Tulane University,
the one exhibit by Drs. George E. Burch and T.
Winsor, the other by Drs. H. T. Engelhardt and
V. J. Derbes. The first of these two exhibits was
on the “Clinical Applications of Phlebomanometer”
and the second one was on “The Heart in the
Asthmatic Child.”

A REQUEST

The Journal is completely out of the February
1943 and 1944 numbers, and would greatly ap-
preciate any help that might be given to the Jour-
nal by physicians who may have these numbers
and who would be willing to donate them to the
Journal. Constant requests have come in for these
particular issues and we are unable to grant these
requests because we have no more copies.

INFECTIOUS DISEASES IN LOUISIANA
The Louisiana State Board of Health reported
that for the week ending May 13 there were re-
ported 36 cases of pulmonary tuberculosis, 31 of
measles, and 12 of mumps. There were no other
diseases reported in numbers greater than 10, a
really very remarkable morbidity record. Of the
unusual diseases there were listed four cases of
poliomyelitis and seven cases of typhoid fever were
scattered over the state, no one parish having
more than one case. Were it not that eight cases
of mumps originated in army camps in this par-
ticular week there would have been only two dis-
eases occurring in double figures. The week
ending May 30 was not quite as good as the
previous week. During this week there were listed
74 cases of measles, 54 of mumps, 51 of malaria,
27 of pulmonary tuberculosis, 12 each of unclassi-
fied pneumonia and of meningococcus meningitis,
and 10 of septic sore throat. There were seven
cases of poliomyelitis reported this week, four from
Orleans Parish and the other three from miscel-
laneous parishes in the state. A large number of
meningitis cases were also more or less sporadic.
Jefferson Parish had four such cases, Orleans
Parish two, and the remainder were distributed
no more than one to a parish. For the week ter-
minating May 27 there were listed 34 cases each
of septic sore throat and of measles, 30 of pul-
monary tuberculosis, 20 of unclassified pneumonia,

Louisiayia State Medical Society News

37

27 of mumps, 24 of malaria. There were four
cases of poliomyelitis reported this week, five of
typhoid fever, and four of meningitis. The week
ending June 3 contained the venereal disease sta-
tistics for the previous four weeks. During this
period of time there were reported 1,233 cases of
syphilis, 1,170 of gonorrhea, 67 of chancroid, 12
each of lymphopathia venereum and of granuloma
inguinale. In addition to these diseases that are
reported each month, the following diseases that
are reported weekly occurred in double figures, 37
cases of septic sore throat, 31 each of measles and
of unclassified pneumonia, 23 of mumps, 16 of
malaria, and 13 of pulmonary tuberculosis. This
week Terrebonne and Orleans Parishes each re-
ported two cases of poliomyelitis and St. Helena
one. There were only three cases of meningococcus
meningitis.

It must not be forgotten that many of these
infectious and reportable diseases are reported
from military sources as for example the 16 cases
of malaria which were listed this week, and the
same may be said of mumps.

HEALTH OF NEW ORLEANS
The Bureau of the Census, Department of Com-
merce, reported for the week ending May 20 there
were 148 deaths in the City of New Orleans as
contrasted with 139 the previous week. Of these
deaths there were 103 in the white population of
the city and 45 in the colored. The total number
of deaths also comprised 20 deaths in children
under one year of age, 12 white, 8 negro. The
following week there was a sharp decline in the
total number of deaths among the people of New
Orleans. There were 119 people dying this week,
65 of whom were white, 54 of whom were colored,
and 15 of whom were under one year of age. The
death rate went up in the city in the week which
ended June 3. Of the 134 deaths, 92 were in the
white, 42 colored, and 25 in small infants. The
death rate in the City of New Orleans is lower
than 1943, at which time it was the lowest that it
has ever been in the annals of the city. There have
been approximately 163 less deaths in the first 22
weeks of the year than there were in 1943.

DR. NICHOLAS F. BRAY
(1880-1944)

Dr. Nicholas F. Bray of Springfield, La., was
born in 1880 and graduated from the St. Louis
Physicians and Surgeons College in 1908. He had
been a resident of Springfield for twenty-five
years. He died in Springfield on June 16, 1944.

DR. ERASMUS DARWIN FENNER
(1868-1944)

It is with sincere regret that we record the
passing of Dr. Erasmus Darwin Fenner, one of
the outstanding physicians of New Orleans. Dr.

Fenner was known not only on account of his
supreme skill in his specialty, surgical diseases of
children, but also because of his delightful per-
sonality. He was a man who was admired and
respected and liked by his colleagues and by his
friends.

Dr. Fenner was at one time Professor of Ortho-
pedic Surgery at Tulane, retiring on account of
age. For over fifty years he was connected with
Charity Hospital, and in spite of the fact on ac-
count of age he was made emeritus member of the
staff, he still continued his interest in this institu-
tion and in the small child, to untold thousands of
whom he had given surcease and made their lives
happy.

Dr. Fenner’s medical career is an example to
all young men, but in addition to the good deeds
that he did he was active in organized medical
circles and former president of the Orleans Parish
Medical Society among other positions that he held
in the organization. He was a member of Base
Hospital Unit Number 24 (Tulane) in 1917 where
he obtained the rank of major.

Dr. Fenner’s grandfather was one of the out-
standing physicians of the state in his day, and a
founder of the New Orleans Medical and Surgical
Journal.

A loved member of the medical profession has
just died. We all who knew Fenner grieve at his
going and feel that he left a mark in medical cir-
cles in the City of New Orleans and the State of
Louisiana which will be lasting.

DR. SAMUEL CLYDE FITTZ
(1880-1944)

The following is an extension of remarks of the
Honorable A. Leonard Allen of Louisiana relative
to the death of Dr. Fittz. It seems appropriate
to publish in part these remarks:

“Mr. Speaker, one of the closest friendships I
ever formed was with Dr. Samuel Clyde Fittz of
my home town, Winnfield, La. In his death which
occurred May 14, 1944, I have sustained the great-
est loss of personal friendship. Dr. Fittz for more
than a quarter of a century was my family phy-
sician. For a great many years we had adjoining
offices. His sudden death has removed one of the
most influential and useful citizens which my sec-
tion of Louisiana has ever produced. Always
sympathetic, always coux-teous, always ready to
serve his fellow man, Dr. Fittz really gave his
life for others. He wox-ked in the heat, in the
cold, in the night, and in the day, without sleep,
without rest to minister to the needs of others.”

DR. JAMES ARTHUR TUCKER
Whereas the Supreme Physician has seen fit
to remove from our midst Dr. James Arthur
Tucker, able physician, honorable man and loyal
friend and,

Whereas in the passing of Dr. Tucker, we have

38

Book Reviews

suffered an irreparable loss, and will miss the
profound wisdom of his judgment, therefore be it
Resolved that this resolution of sorrow at his
passing be incorporated into the records of the
East Baton Rouge Parish Medical Society, a copy
sent to the N. O. Medical and Surgical Journal,
and a copy sent to his family.

East Baton Rouge Parish Medical Society
Lester J. Williams, M. 0.

H. Guy Riche, M. D.

Tom Spec Jones, M. D.

Committee.

DR. WILLIAM I. HUNT
It is with deep sadness that we record the death
of Captain William I. Hunt, M. C., who graduated
from Tulane Medical School in 1942, served an
internship at the Charity Hospital and then entered
the Armed Services. Previously cited for bravery
in action, Hunt was killed June 6, in the Southwest
Pacific area.

A fine looking, serious, hard-working young
man, Hunt’s death will be a great shock to his
many friends.

WOMAN’S AUXILIARY

MONTHLY REPORT OF THE WOMAN’S
AUXILIARY TO THE LOUISIANA STATE
MEDICAL SOCIETY— JUNE, 1944
Although meetings of the Auxiliary are, of ne-
cessity, suspended for the summer months, the
regular activities of the association are carried on
by the officers and committees of the group.

Mrs. Rhodes Spedale, president, announces the
names of the following officers, elected and in-
stalled at the annual meeting of the auxiliary held
in New Orleans, April 25:

President-elect, Mrs. Paul G. Lacroix, 3132 State
St., New Orleans; First Vice-President, Mrs. Ar-
thur Long, 1367 Steele Drive, Baton Rouge; Second
Vice-President, Mrs. Carroll Gelbke, 44 Willow
Drive, Gretna; Third Vice-President, Mrs. 0. B.
Owens, 1931 Military Highway, Pineville; Fourth
Vice-President, Mrs. B. C. Garrett, 4700 Fairfield,
Shreveport; Treasurer, Mrs. R. D. Martinez,

Plaquemine; Recording Secretary, Mrs. Frank
Jones, 810 Park Blvd., Baton Rouge, and Corre-
sponding Secretary, Mrs. E. C. Melton, Plaquemine.

Appointed as chairmen of standing committees
are: Archives, Mrs. J. Kelly Stone, 72 Fontaine-
bleau Drive, New Orleans; Bulletin, Mrs. R. T.
Lucas, 535 Pierremont Road, Shreveport ; Cancer
Control, Mrs. Lloyd Kuhn, 4317 So. Miro St., New
Orleans; Doctors’ Day, Mrs. George Taquino, 18
Fontainebleau Drive, New Orleans; Finance, Mrs.
M. C. Wiginton, Hammond; Hygeia, Mrs. De Witt
Milam, 1704 Island Drive, Monroe; Indigent
Widows, Mrs. Aynaud Hebert, 2013 Napoleon Ave.,
New Orleans; Legislation, Mrs. C. Grenes Cole,
4938 St. Charles Ave., New Orleans; Organization,
Mrs. Phanor L. Perot, 1405 Park Ave., Monroe;
Parliamentarian, Mrs. A. A. Herold, 1116 Louisi-
ana Ave., Shreveport; Press and Publicity, Mrs.
Edwin R. Guidry, 720 Broadway, New Orleans;
Printing, Mrs. D. J. Murphy, 137 S. Solomon St.,
New Orleans; Program, Mrs. C. B. Erickson, 423
Herndon Ave., Shreveport; Public Relations, Mrs.
J. E. Heard, 512 McCormick St., Shreveport; Red
Cross, Mrs. C. M. Horton, Franklin; Revision of
By-Laws, Mrs. Roy Carl Young, Covington; and
War Participation, Mrs. S. L. Calhoun, 2241
Thornton Court, Alexandria.

To supervise group work as councilors for the
year will be: First District, Mrs. H. T. Simon,
1300 Third St., New Orleans; Second District,
Mrs. Roy B. Harrison, 2327 Napoleon Ave., New
Orleans; Third District, Mrs. Guy Jones, Lock-
port; Fourth District, Mrs. T. E. Strain, 525
Wilder Place, Shreveport; Fifth District, Mrs. R.
W. O’Donnell, 117 Stone Ave., Monroe; Sixth Dis-
trict, Mrs. Wiley A. Dial, 1137 Blvd., Baton Rouge;
Seventh District, Mrs. Walter Moss, Drew Park
Drive, Lake Charles; and Eighth District Mrs.
A. L. Culpepper, 226 Bolton Ave., Alexandria.

Auxiliary members having business to conduct
should get in touch with the individuals heading
the groups as designated.

Respectfully submitted,

Mazie Adkins Guidry,
Chairman of Press and Publicity.

BOOK REVIEWS

Maurice Arthus’ Philosophy of Scientific Investi-
gation: Translated by Henry E. Sigerist with a
foreword by Warfield T. Longcope. Baltimore,
The Johns Hopkins Press, 1943. Pp. 26. Price,
$0.75.

Maurice Arthus’ brilliant work on anaphylaxis
is known to all allergists. In the preface to “De
l’anaphylaxie a l’immunite” published in 1921,
he gives sound advice to the experamentalist in
science. The preface is short, stimulating, and re-
freshing. It states clearly the necessary attributes

for the scientific mind in doing problems of re-
search. In a review it is only possible to mention
some of the high spots in his discussion.

Conclusions drawn from scientific investigations
are solid and lasting only if they are based on as
complete as possible a study, accurately and min-
utely conducted. When generalizations are based
on many cases, each should be based on careful
study.

A theory is not a fact. There is a danger in
holding to theories. A theory is a dogma, based

Book Revieivs

39

on faith, which may or may not be true. A theorist
is a partisan and defends his ideas by all possible
means. There is a tendency among young scien-
tists to accept theories as facts. Theories are
treacherous and seductive.

The proper method of scientific investigation
is to conceive a hypothesis (a hypothesis is not a
theory but merely a question), then ascertaining
the value of this hypothesis experimentally, inter-
preting the experiments and then criticizing the in-
terpretation vigorously and strictly.

An important thing is the possession of certain
moral qualities, and scientific curiosity, which is
not content with looking casually at certain facts
and giving them any kind of interpretation. The
fact must be studied and analyzed. The experi-
mentalist must have a straight, clear, and precise
mind.

If an observation has been made causing a series
of hypotheses or questions, orienting research in
various directions, the experimentalist will select
only one, the one with the greatest promise. The
others are discarded at least for the time. In
this way the borderlines are established with pre-
cision, and he avoids being driven into sidelines
which turn him away from the essential object
of his research. Tenacity in determining the worth
of a hypothesis is important. If examination and
meditation on the subject of research does not help,
stubborness should be avoided. The question may
be merely kept in mind, and later the study may
be reopened.

Facts and their interpretations and meanings
may be held true and valid only when they have
met the indispensable test of scientific criticism.
This presupposes a special mental attitude, namely
critical sense. The critical spirit, by the way, has
nothing in common with the spirit of systematic
opposition, or with the spirit of disparagement.

The experimentalist must have patience and self
control. Practical applications may present them-
selves, but we should not be pulled away from our
main investigation with the idea of coming to it
again later.

Enthusiasts and careerists may lose the spirit
of independence and the spirit of originality, and
their scientific work may be dull and colorless.
Independence and originality may be maintained
by open discussion, mental reservations about
things that are taught, and by criticism.

Henry D. Ogden, M. D.

Parasitic Diseases and American Participatio7i in
the War: By Horace W. Stunkard, Lowell T.
Coggeshall, Thomas T. Mackie, Robert Matheson
and Norman R. Stoll. New York Acad, of Sci.,
Vol. XLIV, Art. 3. Pp. 189-262. Sept. 30, 1943.
Price, $1.00.

This is the series of papers presented before the

Section of Biology, New York Academy of Sci-
ences, on March 13, 1943, and contains in addition
to an introduction by Professor Stunkard the cur-
rent views of authorities in special fields of human
parasitology, viz., protozoa (Coggeshall) , helminths
(Stoll), arthropods (Matheson) and clinical para-
sitology (Mackie). Brief discussions following the
presentation of each paper are included. In addi-
tion to the interesting opinions expressed, there
are several pages of solid facts and numerous
bibliographic references.

Ernest Carroll Faust, Ph. D.

Psychosomatic Disturbances in Relation to Person-
nel Selection: By Lawrence K. Frank, M. R.
Harrower-Erickson, Lawrence S. Kubie, Gard-
ner Murphy, Donal Sheehan, and Harold G.
Wolff. New York Annals of the New York
Academy of Sciences, Volume XLIV, Art. 6.
Dec., 1943. Pp. 539-624. Price, $1.00.

This book is a timely one. The chapter by Mr.
Frank is extremely stimulating and offers a vision
of the future reorientation in education, particu-
larly medical education. So far as psychologic dis-
orders are concerned, the following chapters are
each contributory toward a better appreciation of
the selection of leaders and followers in any sort
of group life, military or otherwise. Dr. Har-
rower-Erickson’s chapter on the Rorschach brings
out the very practical utility of this test in organic
disorder. The chapter by Mr. Gardner Murphy is
a comprehensive assay and synthesis on the use
of psychological tests. The chapter by Dr. Kubie
is an especially useful one and provocative of con-
siderable thought and re-valuation of medical con-
cepts. All in all, the book is interesting, informa-
tive, and well worth-while reading.

T. A. Watters, M. D.

Principles and Practice of Medicine, originally
written by Sir William Osier, Bart., M. D., F.
R. C. P., F. R. S.: By Henry A. Christian, A. M.,
M. D., LL. D., (How.) Sc. D., How. F. R. C. P.
(Can.) 15th ed. New York, D. Appleton-Century
Co., 1944. Pp. 1498. Price, $9.50.

When a book has achieved a fifteenth edition it
became superfluous either to condemn or commend
it to the profession. A book that has survived
fifty years of cataclysmic cosmic change has placed
itself beyond the reach of carping critics. It has
become as much an integral part of American liv-
ing as the ham sandwich and coke for luncheon.
Generations of medical students have known no
other guide than Osier so that enquiries as to
other great teachers in American medicine would
bring forth expressions of indecision and uncer-
tainty. Since the days of Osier, the editors have

40

Book Reviews

been Osier and McCrae, McCrae and now Chris-
tian, until we now have a new testament concern-
ing the words of Osier according to McCrae and
according to Christian. And this to me is hardly
a Christian virtue. For by this time I doubt if
anyone can tell which are the original thoughts
and words of Osier, which the amendations of
McCrae and which the medical distillate of the
knowledge and wisdom of Christian. One wonders
whether the name Osier is not employed as an
“Open sesame” to prospective purchasers of new
principles and practices for present-day physicians.
But if Osier is retained as a tribute to an immor-
tal in medicine it is both fitting and appropriate.
It is a big book of over 1500 pages. The editor has
succeeded admirably in bringing it up to date.
Samplings from many parts of the book reveal
most recent information concerning diagnosis and
treatment. Briefly put, one can peruse its pages
with the assumption that here is a volume to com-
pare most favorably with the most reliable data in
current literature. This is hardly surprising when
one remembers that Christian sans Osier sans Mc-
Crae is one of the great contemporary American
teachers. The tradition of Osier, well perpetuated,
is admirably carried on in this new addition. There
are some minor objections about the format of the
book but we must remember messieurs, “c’est le
guerre,” pardonnez^moi.

I. L. Robbins, M. D.

Textbook of General Surgery: By Warren H.

Cole and Robert Elman. New York, D. Apple-
ton-Century Co., 1942. 4th ed. Pp. 1118.

I am certain that the ideal textbook of surgery
has not been written but this “Textbook of General
Surgery,” fourth edition, comes near being one.
The subject matter is presented as far as possible
from the physiologic point of view. Pathogenesis
has been emphasized in order that one may better
perscribe the right therapy.

Great many advances have been made in sur-
gery which made it necessary completely to reset
the fourth edition. Chapters were revised and
now ones added in order to present a systemic
survey of the field of surgery.

The book together with current and other litera-
ture should be helpful to the undergraduate and
graduate student.

Reynold Patzer, M. D.

Physical Foundations of Radiology: By Otto Glas-
ser, Ph. D.; Edith H. Quimby, Sc. D.; Lauris-
ton S. Taylor, Ph. D.; and J. L. Weatherwax,
M. A. New York and London, Paul B. Hoeber,
Inc. 1944. Pp. 426. Price, $5.00.

A volume of this title by any one of the four

authors with such extensive experience in the
teaching of radiologic physics would result in a
valuable text. The collaboration of the group has
produced an outstanding and an indispensable
book. It is remarkable that so much material has
been condensed into such a relatively small volume.
The bibliography, however, adds considerable po-
tential information.

The book is divided into nineteen chapters. The
history, apparatus and fundamental principles of
radiologic physics are considered in the first nine
chapters. Measurements of x-ray quantity and
quality and tissue dosage are included in Chapters
X, XI and XII, respectively. The next four chap-
ters deal with natural and artificial radioactive
elements. The measurement of gamma ray quan-
tity and the expression of radium dosage in gamma
ray roentgens for the various types of application
are timely and should aid materially in the univer-
sal adoption of this standard term for radium
therapy. By the employment of the text and tables
it is possible to convert the older expression of
dosage in milligram-hours and millicurie-hours to
gamma roentgens. The section on nuclear physics
should serve as a background for a better under-
standing of this new form of radioactivity.

Chapter XVII is concerned with the relation-
ship of biologic reaction to quality and intensity
of radiation. In the Eighteenth Chapter, valuable
suggestions are offered regarding roentgen-ray
and radium therapy records. Roentgen-ray and
radium protection is considered in the last chapter.
The appendix containing roentgen-ray depth dose
tables is a valuable addition to the work.

This book was written for physicians preparing
to enter the field of radiology and for radiologists
who desire a review for further information. It
should serve as a necessary handbook to all radio-
therapists.

J. N. Ane, M. D.

Manual of Human Protozoa: By Richard R. Kudo,
D. Sc. Springfield, 111., Charles C. Thomas,
1944. Pp. 125. 29 Figs. Price, $2.00.

This small octavo handbook provides at a glance
the more important morphological and biological
information concerning the parasitic protozoa of
the digestive tract, those which develop in stale
feces, those parasitic in the circulatory system and
those in the muscles and reproductive organs. Spe-
cial emphasis is placed on the species known to be
pathogenic, viz., Endamoeba histolytica, Balanti-
dium coli, Trypanosoma gambiense, T. rhodesiense
and T. cruzi, Leishmania donovani, L. tropica and
L. brasiliensis, the malaria parasites, Isospora
hominis and Sarcocystis lindemanni.

Contrary to the unanimous recommendation of
the International Commission on Zoological No-
menclature (Opinion No. 99, 1928) the author in-

Book Reviews

41

sists on using “Entamoeba” for “Endamoeba". He
also employs the older, moi-e conservative spelling
in such words as “diarrhoeic faeces” (p. 36). The
zoologic information presented is both accurate and
up to date. In diagnosis, however, no mention is
made of the zinc sulphate centrifugal floatation
for the concentration of protozoan cysts in a diag-
nosable stage from the feces, or of D’Antoni’s
iodine stain. Both of these technics, developed in
recent years in the department of tropical medi-
cine of Tulane University, have received wide
recognition in public health and clinical labora-
tories in North America and Latin America. The
little volume does not take up the clinical aspects
of the infections produced by protozoa.

The format and typography are pleasing, typo-
graphical errors are very few and the illustrations
are excellent, although some of them suffer from
too great a reduction.

Ernest Carroll Faust, Ph. D.

Applied Dietetics: By Frances Stern. Baltimore,

Williams & Wilkins, 1943. Pp. 265. Price, $4.00.

On glancing over this well organized book on
dietetics, one is struck by the large number of
tables giving all sorts of information on food val-
ues. The sources of various minerals, vitamins,
along with detailed description of bodily needs for
these substances are here at the physician’s fin-
gertips.

There is an interesting section on the education
of the patient in matters of diet. The author goes

to great length to describe the needs of a normal
individual and also presents sources of material
for therapeutic diets.

This book is obviously one that should also prove
to be of help to the laity, nurses, social workers,
dieticians.

Henry D. Ogden, M. D.

PUBLICATIONS RECEIVED

W. B. Saunders Company, Philadelphia and
London: Hydronephrosis and Pyelitis (Pyeloneph-
ritis) of Pregnancy, by H. E. Robertson, M. D.

Lea & Febiger, Philadelphia: Bacterial Infec-
tion, by J. L. T. Appleton, B. S., D. D. S., Sc. D.

J. B. Lippincott Company, Philadelphia and
London: Principles and Practices of Inhalational
Therapy, by Alvan L. Barach, M. D.

Paul B. Hoeber, Inc., New York and London:
Infections of the Peritoneum, by Bernhard Stein-
berg, M. D. Physical Medicine in General Prac-
tice, by William Bierman, M. D.

Charles C. Thomas, Springfield, Illinois and Bal-
timore, Maryland: Psychiatry and the War, edited
by Frank J. Sladen, M. D.

The Williams & Wilkins Company, Baltimore,
Maryland: Radiation and Climatic Therapy of
Chronic Pulmonary Diseases, edited by Edgar
Mayer, F. A. C. P., F. A. C. C. P.

Columbia University Press, New York: One
Hundred Years of American Psychiatry, published
for the American Psychiatric Association.

UNITED STATES WAR
BONDS and STAMPS

New Orleans Medical

and

Surgical Journal

Vol. 97 AUGUST, 1944 No. 2

SOME POSTWAR PROBLEMS IN
MEDICAL EDUCATION*

LEWIS H. WEED, M. D.f
Baltimore, Md.

With twenty-seven months of war behind
us and with an unknown number of months
of war ahead, we are meeting today to wit-
ness the formal conferring of degrees upon
a class of medical students who have com-
pleted the first important phases in their
training as physicians. We cannot divorce
these exercises from the war itself for most
of this class before me is in uniform and
its members constitute part of the Armed
Forces of the United States. Realization
that medical schools are playing their role
in the war effort, that they are really a
functional part of the medical departments
of the Army and Navy, makes me appreci-
ate more fully the high honor which The
Tulane University of Louisiana has done
me in asking me to speak at these war-
time Commencement Exercises. Tulane has
a most distinguished and interesting his-
tory as a University with its medical school
as its oldest element: it has achieved high
renown in meeting so completely and hap-
pily its academic and professional obliga-
tions. And in this war as in others past,
Tulane’s duties in the public service are be-
ing faced courageously and successfully.

This war has already had its great effect
upon medical education, not only upon the
strong outstanding schools like Tulane but
also upon those schools with lesser financial

* Address at Commencement Exercises, delivered
to graduating class of Tulane University of Louis-
iana Medical School, February 12, 1944.

-{-Director, School of Medicine, Johns Hopkins
University.

support and with lesser educational oppor-
tunities. Shortly after the European phase
of the war blazed into a total conflict, medi-
cal schools in this country began to feel the
initial repercussions of the war. First no-
ticed were the occasional withdrawals of
faculty members for unheralded prepara-
tory work in Washington, and there were
the rearrangements of personnel in the
sponsored hospital units which had been
organized some years before in the large
university hospital centers. Then with the
President’s declaration of a “limited emer-
gency” (September 8, 1939), and with the
re-creation of the Council of National De-
fense, the medical schools of the country
began to experience more fundamental ef-
fects of the whole defense program. The
passage of the Selective Service act added
another stimulus to the preparations for ac-
tual warfare ; this act necessarily had its
reflections in all under-graduate colleges
and professional schools. Almost without
due and deliberate consideration, medical
schools in this country adopted an accele-
rated schedule of instruction, whereby the
long vacations were eliminated and the
teaching progressed almost continuously
through four academic years of nine
months each, to complete the course with-
in three calendar years.

As you will recall, the administrative
steps in preparation for war followed in
rapid succession. The partial emergency
was converted into a total “unlimited”
emergency (March 27, 1941), and various
new organizations were created by Execu-
tive Orders of the President. When war
finally came immediately after Pearl Har-
bor (December 8, 1941), the medical

44

Weed — Postwar Medical Education

schools responded in valiant fashion. Facul-
ties were momentarily disrupted by the
withdrawal of the sponsored units for ac-
tive duty and the student bodies soon be-
came partially militarized by the commis-
sioning of the physically fit males as re-
serve officers in the Medical Administra-
tive Corps of the Army or in the Hospital
Corps of the Navy. With that step taken,
it was not long before the formation of a
students specialized training corps was pro-
posed ; and after the adoption of a federal
plan of technical training, students in medi-
cine, dentistry and veterinary medicine
were brought into the Armed Forces under
a program originally designed for the
physicist and the engineer. Then, too, pre-
medical educational opportunities were cut
sharply to fifteen months of college work
for the Army and to a slightly more liberal
allowance for the Navy. Into these months
of premedical work, the minimal require-
ments in chemistry, physics and biology
were crowded.

So today we see an almost complete
militarization of medical education — the
production of physicians has largely become
a federal function, for the Government
must have an assured supply of doctors for
the Armed Forces and the civilian needs
must not be neglected. And in this overall
plan of medical training, provision has been
made for abbreviated internships and for a
small number of hospital residencies.
Throughout the whole program of under-
graduate medical education and postgradu-
ate hospital experience, acceleration and
condensation are outstanding characteris-
tics. To maintain quality of instruction and
quality of clinical work medical institutions
must struggle vehemently ; faculties are to-
day striving and sacrificing themselves to
uphold essential intellectual standards.

During these months of readjustment of
medical education, the national program in
medicine was going forward in spite of dif-
ficulties, inherent in the transformation of
a peace-time system into a war-time activi-
ty. In 1940, the medical departments of
the Army and the Navy re-studied the pre-
pared plans for enlargement of their serv-

ices and began the initial enrolling of re-
serve officers. In this period, the relation-
ship of military to civilian medicine was
carefully considered. The Division of Med-
ical Sciences of the National Research
Council was early brought into the picture
(May, 1940), when the Surgeons General
requested the quasi-governmental Council
to organize civilian committees to serve in
an advisory capacity. A few months later
a Health and Medical Committee was ap-
pointed by the President under the Coun-
cil of National Defense. This Committee,
charged broadly with the national problems
of medicine and public health, was soon
transferred to the Federal Security Agency,
under the Coordinator of Health, Welfare
and Related Defense Activities. In the
transfer, the Health and Medical Commit-
tee, which had only meagre funds at its
disposal, was deprived of its executive
functions; medical research pertaining to
the war effort was not adequately financed
through this Board. The committees of the
Research Council, however, continued to
meet the many requests for professional
advice but the pressing problem of ample
subvention of war research was not solved
until the early summer of 1941 when the
Office of Scientific Research and Develop-
ment was established by Executive Order
of the President. This Office was charged
with responsibility for study of the instru-
mentalities of warfare through its already
established National Defense Research
Committee and was further instructed to
form a Committee on Medical Research
which should deal broadly with medical in-
vestigations pertaining to the war effort.
The Committee on Medical Research co-
opted the committees of the National Re-
search Council and has continued to use
these bodies as advisory agencies. Ade-
quate funds have been provided by Con-
gressional appropriations to the Office of
Scientific Research and Development and
today a large proportion of the competent
medical scientists in this country are work-
ing on investigative projects directly con-
nected with the war effort and financed by
Government contract.

Weed — Postwar Medical Education

45

The type of research necessarily has to
be focused on those problems which direct-
ly pertain to military medicine and much
of the work therefore has a very definite
practical application. On the other hand,
tne members of the Committee on Medical
Research have been aware that certain of
the problems of military medicine can only
be advanced by definite attack on funda-
mental mechanisms and these aspects have
not been neglected. The problems range
widely from those of aviation medicine,
gas casualties, malaria, neuropsychiatry,
shock, tropical diseases, surgery, venereal
diseases, blood substitutes to the wholly
practical studies of physical standards of
recruits. In this wide effort Government
funds approximating $7,500,000 and in-
volving over 400 separate projects are be-
ing devoted to the purpose during the cur-
rent year. And it must be a matter of
great satisfaction to the faculty of Tulane
University that certain very important in-
vestigations here within the University are
being carried forward under federal con-
tract.

This background of almost four years of
medical effort in Washington and the coun-
try at large is necessary for us to appreci-
ate the postwar problems which will con-
front every educational institution and
university hospital. It was easy enough for
medical schools to accelerate their pro-
grams of teaching but the problems of de-
celeration will be profound. The mechan-
isms of readjustment of the present cur-
riculum to the old academic procedures can
be minimized though they will cause many
a difficulty to deans and to curriculum com-
mittees. But to speak of deceleration im-
plies that medical schools will return to the
prewar type of medical instruction over
four calendar years during which the stu-
dents followed a course characterized by
some critics as one of academic leisure.
The advantages of this relatively slow
course of instruction lay in the fact that it
gave the faculties sufficient time for ade-
quate and enthusiastic preparation for
teaching, that it gave the students oppor-
tunity for the absorption and digestion of

medical instruction. In spite of critical
statements, medical teachers in general be-
lieve that the four years were busy years
for the students: unquestionably the pre-
war schedule resulted in the production of
first-class, well-trained medical men.

Assuming then that wisdom bids us re-
turn to the prewar plan of a four-year
course of study, it is obvious that medical
schools will face many important changes
in the curriculum. The war with its wide
dispersion of troops throughout the world
has already demonstrated the need for ad-
ditional emphasis on tropical diseases — a
subject in which Tulane almost alone of
medical schools has developed in a distin-
guished manner. Then, too, preventive
medicine in the widest sense (sanitation,
epidemiology, industrial medicine) will be
represented in a larger way in the cur-
riculum. Revision of the curriculum is in-
evitable but such revisions are always the
periodic concern of faculties.

But the postwar medical school will be
confronted with other highly complex and
perplexing problems. Many of the medical
officers in the Armed Services, particularly
those of the younger group, will desire ad-
ditional academic work in their chosen field
of medicine. Many of these physicians will
be without sufficient funds, and if the med-
ical schools are to provide adequate post-
graduate opportunities for these men,
fellowships must be made available, either
through federal or state grants, through
university stipends, or through foundation
support. The group of these eager young
men will be large, for with 50,000 medical
officers in the Armed Services and with the
war now proceeding into its third year,
there will be several thousand who will feel
the need for additional instruction, for hos-
pital work, and for training in the medical
specialties. It is questionable whether the
medical schools of the country will be able,
on the present basis, to provide the needed
opprtunities, as the schools were before the
war operating at capacity and accepted only
those undergraduate students who could be
provided with ample facilities for labora-
tory and clinical instruction.

46

Weed — Postwar Medical Education

One of the obvious problems of the post-
war medical school will center about the
necessary readjustments of the premedical
courses with the substitution of a two-year
or four-year college course for the present
fifteen months. Such a lengthening will
inevitably disturb the flow of students into
medical schools for one or more years. It
has been suggested that one of the wise
steps to be taken by some American medical
schools would be to close the doors of the
institutions to new students for a period
of two or three years. The institutions
could then devote their major efforts to
the postgraduate training of returning
medical officers so that this group of young
physicians would go out into medical prac-
tice with renewed enthusiasm and with full
knowledge of recent advances. During this
period the premedical students, now hasten-
ing through the accelerated fifteen months’
preparation, would develop a desirable in-
tellectual maturity and a better preparation
for their future undertakings. There would
be a return to the type of premedical prep-
aration which was insisted upon before the
war by all of the better medical schools of
the country.

Such a proposal, however, requires con-
sideration of its practicality. The mere fi-
nancing of the whole procedure, whereby
undergraduate student fees would be large-
ly eliminated and whereby funds for
fellowships and postgraduate training
would necessarily have to be provided, pre-
sents a problem of utmost difficulty. Per-
haps the well endowed schools would look
upon the procedure as one of sufficient
merit to justify expenditure of endowment,
were it permitted ; perhaps state, municipal
or federal financing could be achieved ; or
perhaps also private or foundation support
could be obtained. Against the proposal
would be argued the partial interruption of
production of new medical graduates who
would be needed by the hospitals for interns
and residents. Again and again the finan-
cial problem will creep to the fore. Medical
schools will need all possible funds, for the
income from endowments will continue to
be very low, tuition fees will necessarily

remain approximately unchanged, and sal-
aries for professional and technical staffs
will have to be increased to compensate
for the fall in the purchasing power of the
dollar.

Wholly apart from such financial con-
siderations, it must be realized that our
educational system in medicine during the
past fifty years has been based upon the
major tenets of thorough preparation in
the premedical sciences, of basic training
in the preclinical subjects, of insistence
upon bedside teaching, with its adjunct of
laboratory control. Throughout the whole
process the development of the inquiring
attitude of mind in the students has been
the aim of medical teachers, but we are
today laboring under a system which has
become antiquated due to the wide spread
of research interests. Medical schools uni-
versally possess departmental organiza-
tions where teaching is confined to the
proper cubicle, labelled with one of the es-
tablished subjects of medical instruction.
Medical research, however, has broken
down the border between these compart-
ments ; and the department has become
merely a convenient teaching mechanism.
The anatomist, who is responsible for in-
struction in the structure of the body, feels
free today to extend his investigations by
physiological methods and to work wher-
ever his particular problems lead him. The
departments, with their confines of teach-
ing facilities, will probably continue, but
during the past three decades the whole
subject of medicine has so widely expanded
in many special directions that medical
schools are no longer able to provide com-
plete opportunities for medical instruction.
No single institution is able, under the pres-
ent distribution of medical talents in some
sixty-six medical schools in this country, to
supply instruction, under competent teach-
ers, for the special preparation and special
training required in all of the many facets
of medicine.

Two alternatives immediately present
themselves. The continental system of mi-
gration of students to outstanding pro-
fessors presents a possible solution; but in
spite of the encouragement given to such

Weed — Postwar Medical Education

47

migration in certain medical schools during
the past twenty years, the procedure has
been followed only rarely by the students,
and then with greatest difficulty because
of curricular divergencies in the various
schools. Migration is also costly to the
student and it is unlikely in America to
afford the wide opportunity which the med-
ical student of the future should have avail-
able. Another possible solution of the
problem of providing complete medical
opportunities would lie in the consolidation
of medical faculties. Instead of the present
number of schools we might envisage a
maximum- of twenty or thirty medical in-
stitutions, with consolidated faculties gath-
ered from the existing schools and with
admission of much larger classes. Such
schools would necessarily provide ample
laboratory facilities and could be located
only in those large cities where ample hos-
pital beds are available. These schools
would have the responsibility for complete
coverage of medical subjects and would re-
quire large financing. The cost of medical
education, which has gradually and often
rapidly mounted in the past forty years,
would reach limits which would cause uni-
versity presidents and trustees to shudder.
But such schools, representing the con-
densation of the teaching talents in Ameri-
can medicine, might prove to be capable
of producing a better type of physician,
more widely trained and more effectively
taught by masters who are capable of in-
spiring as well as instructing.

Even if such proposals are considered
now as visionary, it is clear that in the
postwar period medical research will in-
evitably expand and will produce results of
large practical value. It is likely that the
medical departments of the Armed Forces
will continue to work on those problems
which stretch beyond civilian medicine and
which are peculiar to military operations.
On the civilian side, it would be a tragedy to
American medicine if institutional support
of medical research were cut, due to the
lack of funds available to university facul-
ties. Subsidy of medical research by the
philanthropic foundations will, in the na-

ture of things, never prove sufficient for
the national needs in medicine; foundation
subvention will act as a spur to private and
institutional support. In the postwar pe-
riod the demands on the foundations for
other purposes than the support of medical
education and research will unquestionably
be profound and it seems unlikely that any
very large grants can be expected. While
it is very difficult to predict, one could de-
fend the premise that no considerable aug-
mentation of the capital of existing foun-
dations will be forthcoming; it is probable
that many of the present foundations will
gradually and wisely disburse their funds.
With the inevitably high taxes of the fu-
'ture, it is also unlikely that any new foun-
dations of magnitude will be established.

It is in the minds of many educators that
research in the future will be in greater
and greater part financed by grants to uni-
versities from the large industrial com-
panies. These corporations have during the
past few decades developed extraordinarily
competent research groups within their
own organizations and many of them have
been willing to devote their funds to fun-
damental problems in the field of their in-
terests. But these companies must neces-
sarily procure their investigative staffs
from the universities and it is not only
desirable but logical that they should con-
tinue their support of fundamental aca-
demic undertakings. Funds from the out-
standing commercial organizations of this
country have for the most part been un-
conditionally given and universities have in
no way been subject to restrictions in the
clear furtherance of research, with unham-
pered publication of investigative findings.
Here, as in almost all considerations of
medical education and research, financial
factors enter, and they will inevitably enter
in the postwar period.

All of this discussion has presupposed
that medicine in this country will return
to the prewar type of medical practice, of
medical education and research, of hos-
pitalization and of public health procedure.
Such an interpretation at this time is
hardly warranted, for with the various na-

48

Weed — Postwar Medical Education

tional movements well underway it is
wholly unlikely that the pattern of medical
practice, as established during the past few
decades, will survive unchanged. For years
we have listened attentively to many argu-
ments for the socialization of medicine —
arguments based mostly on the fact that
medical skills are not available throughout
the total population. No one can deny that
the proper distribution of medical talents
whereby the entire population receives the
best available medical care is a question of
utmost moment. No one, I feel, would care
to eliminate the very desirable doctor-
patient relationship, but every one would
agree that this relationship might be ex-
tended through some better dissemination
of medical abilities both on the geographic
and economic basis. It would seem inevita-
ble that in the postwar adjustment of
physicians to the needs of the country a
better distribution of physicians, of hos-
pital-facilities and of public health service
would be attempted and possibly achieved.
Every one who has studied democratic gov-
ernment would oppose federal control of all
aspects of medicine and health ; but govern-
ment intervention has, in the development
of public health procedures, been an in-
evitable and useful development of the last
fifty years.

The medical profession of America has
its own problems to solve. If the profession
cannot devise a method of providing the
best of medical care and public health
procedure for the large population of the
United States, there will almost inevitably
follow some type of federal intervention,
as witnessed by bills now pending before
Congress. It has been said many times,
almost to the point of boredom, that the
medical profession itself must do its own
planning if it is to reserve those essentials
of medical practice which the profession
itself feels are paramount to successful ap-
plication of current medical knowledge.
The profession must be helpful in legisla-
tive matters : it must be constructive and
not destructive.

Even if the procedures leading to na-
tional socialization of medicine are avoided

in the next few years it is obvious that
many health programs will be started with
promise of success. The prepayment plan
of hospital insurance has already achieved
great development ; it is a welcome addition
to the insurance benefits of large groups
of individuals. The hospitals of the coun-
try, which have been accepted through one
or another of the organizations, are bene-
fited greatly by the guarantee of hospital
costs, and the individual is able to spread
his risk of hospital needs over a period of
years. The enlargement of the hospital
scheme to include medical service seems
a logical step and in many places the tenta-
tive arrangements are already going for-
ward. The inclusion of physicians’ services
in the prepayment plans presents certain
important problems to the university hos-
pitals in regard to selection of professional
staff and to maintenance of teaching beds.
Yet these difficulties, great as they now
appear to be, would seem capable of solu-
tion. Whatever the changes in medical
practice or hospitalization may be, they
will be, in part at least, reflected in medical
education.

These, then, are but a few of the prob-
lems which medical schools will encounter
in the coming years of peace — problems in
the postgraduate training of discharged
medical officers, in the probable changes
in medical education and medical research,
in the adjustment to a possible change in
medical practice. Are medical schools to-
day thinking of these problems in an ade-
quate way? Are medical schools appointing
committees or designating groups to un-
dertake study of all of these possibilities
of future change so that should peace come
suddenly, or slowly, the faculties would
have definite plans of procedure in the post-
war period? In general, I think, the answer
is No; the unknown and intangible factors
in the postwar adjustment are so diverse
that most faculties feel that they cannot
make a concrete attack upon the problem.
The need is there and it behooves every
medical faculty to take cognizance of these
great changes in medical practice and pub-
lic health, medical education and medical

Major — Instruments of Precision

49-

research which are already showing above
the horizon.

The study of these postwar problems by
medical faculties would be made less diffi-
cult if an effective national committee were
to be appointed by the President to con-
sider all aspects of medical and health
questions. Since the discontinuance of the
Health and Medical Committee some
months ago, several suggestions regarding
a board for overall planning and function-
ing have been made; all of these sugges-
tions point out the need for inclusion in its
membership not only of medical men, but
also of representatives of the public, of la-
bor, of children, of women. There is today
no body with authority to meet the many
problems of medicine and public health in
the national picture; there is no board to
determine the responsibilities of American
medicine in postwar Europe, to advise re-
garding the proper allocation and distri-
bution of available medical supplies, to
study the proper dispersion of physicians
for maximum provision of the health serv-
ices, to plan for the professional employ-
ment of the medical officers on discharge,
to consider broadly the questions of post-
war medical education and research. These
are but a few of the broad unsolved ques-
tions in medicine of the immediate and
postwar period; there is great need for a
national commission to consider them.

So at a Commencement in the midst of
war, we, who have the problems of medi-
cine and particularly of medical education
before us, can point out that there will be
need for the young physicians in any type
of postwar social organization. Fortunate-
ly, the young man who goes forth today as
a doctor of medicine will find that his years
of service in the Medical Corps of the Army
or Navy are not wasted time. In many
branches of the Army and the Navy, war
service contributes in no way to training
for a civilian career; the talents of men
are devoted to tasks which are particularly
those of military effort. In medicine, how-
ever, war presents opportunities not only
by service but for learning : the young med-
ical officer will find that his years of

service will be productive. You young men
are favored in being in a period of rapid
advance in medicine for wars have always
brought forth new knowledge and new
procedures in medicine and public health.
You have before you an impending adjust-
ment to military exigencies and you will
have a postwar problem of additional edu-
cation and of meeting the postwar practice
of medicine. Luckily youth worries not
about security and social organization as
does old age; youth can cope successfully
with social and economic change. Members
of the graduating class, you are fortunate
indeed to have had your medical instruc-
tion in a great university : you now go for-
ward well prepared to meet these imme-
diate and future demands upon you as
physicians. Medicine has its great tradition
of service whether in peace or in war, and
you cannot fail to be aware of your duty
and privilege of maintaining your part in
that high tradition.

o

THE DIAGNOSIS OF DISEASE
WITHOUT INSTRUMENTS OF
PRECISION*

RALPH H. MAJOR, M. D.f

Kansas City, Kansas

I hope the title of this paper does not con-
vey the impression that I advocate the prac-
tice of medicine without the use of instru-
ments of precision. I hope also that this
title may not seem like the credo of a reac-
tionary, who is too sluggish intellectually,
to keep up with the rapid advances in med-
icine and as a defense mechanism “pooh-
poohs” procedures which he either has not
taken the trouble or lacks the ability to
understand. There has never been a period
in the history of medicine, the advances
of which have been comparable to those of
the last century, and most of these advances
have been directly or indirectly the result
of study with instruments of precision.

*Read before the eighth annual meeting of the
New Orleans Graduate Medical Assembly, March
8, 1944.

fFrom the Department of Medicine, School of
Medicine, University of Kansas.

50

Major — Instruments of Precision

There is, however, with every new ad-
vance, a tendency to forget some of the
things that have long been the heritage of
the medical profession, and also to neglect
the simpler methods of diagnosis and ther-
apy for the new ones which have recently
appeared. Some younger physicians appar-
ently forget, for instance, that fluid in the
chest can be diagnosed by physical exami-
nation as well as by the x-rays, and it is
necessary to bring to the attention of many
physicians that Fowler’s solution will often
lower the leukocyte count in leukemia quite
as effectually as the x-ray. Some of these
same individuals would, perhaps, be very
surprised to learn that Hippocrates recom-
mended artificial pneumothorax in the
treatment of pulmonary diseases, and that
Galen was a master of psychoanalysis.
Looking at the matter, however, from the
other point of view, there are many condi-
tions which can be diagnosed only by the
use of instruments of precision ; and with-
out these instruments, many diagnoses, as
well as therapeutic measures, are apt to
be as unsatisfactory as the speculations of
medieval scholastics. On this account, I
shall attempt in this paper to steer a middle
course, and shall point out, from time to
time, certain diseases in which the use of
instruments of precision are just as neces-
sary as their use is unnecessary in others.

At the beginning of any paper, it is,
I believe, customary to define the subject
about which the essayist is going to speak.
In this particular instance, this is rather
difficult. The reason is, of course, obvious.
What is an instrument of precision to one
individual may not be so to the other. There
is also an innate tendency to regard as in-
struments of precision those instruments
which are very complicated, and whose
working the novice does not understand
very well. There is another difficulty
which arises from the fact that what seems
to the uninitiated an instrument of pre-
cision becomes, as one is better acquainted
with and knows its limitations and its pit-
falls, not an exact instrument, but one that
gives only approximate results.

When the stethoscope was first intro-

duced it was considered an instrument of
precision, and the same was true of the
thermometer and the blood pressure appa-
ratus. At the present time they are not con-
sidered by physicians as instruments of pre-
cision any more than the finger tips. This
is due to the fact that most of us have be-
come familiar with these instruments; and
also because this familiarity with them has
shown us that they are, after all, subject to
strange caprices, and can easily lead us
astray.

In discussing this subject we might, per-
haps, make a practical definition by in-
cluding as instruments of precision those
instruments which can only be employed
after considerable special training, which
is not an accomplishment of most members
of the medical profession. I realize that
this classification is rather inexact, but I
shall include under instruments of precision
the x-ray, the electrocardiograph, and va-
rious quantitative laboratory procedures
which can be carried on only in a well-
organized laboratory with special appara-
tus, which can be employed only by persons
with special training.

One of the most important aids a physi-
cian has in the diagnosis of disease is the
history. It is a conservative estimate that
in a great majority of patients the history
obtained from the patient contributes at
least fifty per cent, and according to some,
seventy-five per cent, toward the establish-
ment of a correct diagnosis. It is surpris-
ing how many incorrect diagnoses are the
result of careless history-taking. The his-
tory of a patient who has an inability to
walk in the dark and has lightning pains
in the legs is just as important in the diag-
nosis of tabes dorsalis as the presence of
a positive Wassermann. Similarly in a pa-
tient who gives a history of increasing slug-
gishness, gain in weight, inability to keep
warm at night in bed, increasing dryness
of the hair and roughness of the skin, we
can make a diagnosis of myxedema, and
predict that the basal metabolic test, if car-
ried out properly, will show a rate below
normal.

Volumes have been written on the sub-

Major —Instruments of Precision

51

ject of pain, and in a host of diseases noth-
ing helps us more in the diagnosis than
careful attention to the location and char-
acter of the pain present. In the year 1768
William Heberden, Sr., described a disease
picture which has become classic. Heber-
den, who wrote a chaste Latin, described
the disease as pectoris dolor. His son, who
later translated his father’s work into their
native tongue, English, called it angina pec-
toris; and since that time, it has been known
generally under this term. This descrip-
tion should be part of the reading course
required of all medical students. Heberden
writes :

“They who are afflicted with it are seized
while they are walking (more especially if
it be up hill, and soon after eating) with a
painful and most disagreeable sensation in
the breast, which seems as if it would ex-
tinguish life, if it were to increase or con-
tinue; but the moment they stand still, all
this uneasiness vanishes.

“In all other respects, the patients are, at
the beginning of this disorder, perfectly
well, and in particular have no shortness of
breath, from which it is totally different.
The pain is sometimes situated in the upper
part, sometimes in the middle, sometimes
at the bottom of the os sterni, and often
more inclined to the left than to the right
side. It likewise very frequently extends
from the breast to the middle of the left
arm. The pulse is, at least sometimes, not
disturbed by this pain, as I have had oppor-
tunities of observing by feeling the pulse
during the paroxysm. Males are most liable
to that disease, especially such as have
passed their fiftieth year.

“After it has continued a year or more,
it will not cease so instantaneously upon
standing still ; and it will come on not only
when the persons are walking, but when
they are lying down, especially if they lie
on their left side, and oblige them to rise
up out of their beds. In some inveterate
cases it has been brought on by the motion
of a horse, or a carriage, and even by swal-
lowing, coughing, going to stool, or speak-
ing, or any disturbance of mind.”

This disease has claimed many notable
victims. Among them John Hunter, Mat-
thew Arnold and Charles Dickens. John
Hunter, in describing his symptoms, said
the pain was “as though the sternum was
being drawn back to the spine,” while Mat-
thew Arnold described his sensation during
the attack being “as though there were a
mountain on my chest.”

The most common distribution is over
the sternum and down the inner aspects of
the left arm. This is by far the most com-
mon picture ; but it occasionally varies, de-
pending upon the location of the coronary
constriction.

In the diagnosis of this disease we de-
pend in most instances upon the history,
aided by the physical findings. The elec-
trocardiogram so often leaves us in the
lurch, as it may show little deviation from
the normal. Indeed, I have seen several
patients dying from this disease in whom
the autopsy findings were not characteris-
tic or distinctive. Yet, the history alone of
the affection, as so masterfully portrayed
by Herberden more than a century ago,
permits the diagnosis of the disease in most
instances. The story of a severe pain un-
der the sternum gradually increasing in
intensity and radiating down the left arm
is unlike the story of any other disease.
Pain is a very real phenomenon, and of
real importance in diagnosis, but is, how-
ever, one that has refused to allow itself
to be recorded on any type of a registering
device.

The relatively recent discovery that cor-
onary occlusion is a disease which is both
frequent and important has led unwittingly
to a certain confusion regarding angina
pectoris. Many physicians assume that all
cases of angina are really examples of cor-
onary occlusion and some even suggest the
complete scrapping of angina pectoris as
a clinical term. With this, I personally do
not agree. The term itself, angina pectoris,
cannot be defended as an accurate expres-
sion but if we threw out inaccurate ex-
pressions in diagnosis, we would have to
revamp medical nomenclature.

52

Major — Instruments of Precision

I think there is excellent evidence that
a patient may have attacks of angina pec-
toris for years and never have a true cor-
onary occlusion, and after a time be re-
lieved of all cardiac symptoms. Others
after suffering from angina pectoris for
years may have a fatal coronary attack
or may die without a demonstrable occlu-
sion. To my mind the relationship between
angina pectoris and coronary occlusion has
a close analogy to that between intermittent
claudication and embolism of one of the ar-
teries of the leg. The patient has arterio-
sclerosis of the popliteal artery which pro-
duces intermittent claudication, later a
thrombus forms on the wall of the artery,
is then detached and embolism results.

Another disease which has a very char-
acteristic history is duodenal ulcer. The
characteristic features of the history of
this disease are the chronicity and pain.
Pain on an empty stomach, recurring two
to four hours after meals and relieved by
food and alkalis, is pathognomonic of this
disease. I have noticed that the internists
in our clinic usually make the correct diag-
nosis of duodenal ulcer in most patients
from the history alone, and before the pa-
tient has had a gastric analysis or been in
the hands of the roentgenologist. In a re-
cent examination of one hundred consecu-
tive cases of duodenal ulcer I found that
all of them gave a history of chronicity, of
pain before eating, and two to four hours
after meals, and that all but one were re-
lieved by either food or alkalis and usually
by both. This statement should not be con-
strued as a suggestion that the gastric
analysis and the x-ray examination be
omitted in these cases. Indeed, we carry
out both procedures in every case of sus-
pected duodenal ulcer. It does, however,
stress the importance of the history in the
establishment of the diagnosis of this dis-
ease, and clearly shows that the physician
need not throw up his hands and refuse to
treat a patient with duodenal ulcer because
that physician does not possess an x-ray
apparatus or does not care to carry out a
gastric analysis. Indeed, I have recently
seen a patient who gave a typical history

of duodenal ulcer extending over a period
of several years, who had no treatment be-
cause the physician could find no x-ray evi-
dence of ulcer. This patient had never had
a gastric analysis. The gastric analysis in
our clinic showed a marked hyperacidity,
and our roentgenologist succeeded in find-
ing an ulcer in the duodenum.

Dr. Paul White, in discussing diseases of
the heart, makes the following very sig-
nificant statement. Among the procedures
necessary for correct diagnosis, he says,
“First and most important of all is the
story of the patient. After the history tak-
ing there comes next in importance the
physical examination. Then there follow
methods of less value, but nevertheless of
importance, blood pressure measurement,
roentgenology and electrocardiology.”

Heart disease in the year 1942 was the
cause of 386,141 deaths in the United
States. In no field of medicine have the
advances in accuracy of diagnosis been
more spectacular than in cardiology. These
advances have been due in no small measure
to the employment of instruments of pre-
cision, particularly the electrocardiograph.
It is astonishing, however, how accurate
diagnoses can be made employing only the
procedures of inspection, palpation, per-
cussion and auscultation. While the electro-
cardiogram has been of the utmost value
in explaining, for instance, the mechanism
of various types of arrhythmia, yet these
types of arrhythmia can be diagnosed with
a great deal of precision by simple methods
of examination.

Inspection of the patient, in this era of
instrumental and chemical progress, is in
some danger of becoming a lost art. It
should be pointed out, however, that by in-
spection alone, even unaided by palpation,
we can make a correct diagnosis in a great
variety of cardiac disorders. The pallor of
aortic disease as contrasted with flushed
face of mitral disease, remains as striking
a phenomenon as a century ago. The throb-
bing carotids almost establish the diagnosis
in aortic insufficiency. Cardiac irregular-
ities may usually be clearly diagnosed by
inspection of the cardiac apex alone. Ir-

Major — Instruments of Precision

53

regularities produced by an extrasystole
which is followed by an abnormally long
pause is just as obvious from watching the,
apex as it is in a tracing taken from the
radial artery. Dr. John King has shown
that in bundle branch block there is a bifid,
or double, apex thrust, which is made par-
ticularly visible by strapping an applicator
or a straw at the apex.

The location of the apex gives us, of
course, information of great value regard-
ing the size of the heart. We should also
remember that in mitral disease the apex
is displaced outward, while in aortic dis-
ease it is displaced outward and downward.

These are but a few of the bits of infor-
mation we glean from inspection alone.
Many others occur naturally to our mind
— the slow heart beat of heart block, the
tremendous heart rate of paroxysmal tachy-
cardia.

Even before physicians devoted their at-
tention to inspecting the heart, the pulse
was regarded by the physician as an inex-
haustible storehouse of information. It still
remains so. The physicians of ancient
Egypt two thousand years before the birth
of Christ felt the pulse of their patients.
Rufus of Ephesus, who practiced during the
reign of Trajan in the second century, wrote
a treatise on the pulse, of which Sir Wil-
liam Broadbent in 1890 remarked, “His de-
scription of the different characters of the
pulse leaves little to be added at the pres-
ent day.” Sir James Mackenzie, who con-
tributed most to our knowledge of heart
conditions in his generation by the use of
the sphygmograph and instrumental meth-
ods, wrote the following as late as 1926 : “In
the examination of the arterial pulse sev-
eral methods may be employed, as explora-
tion by the finger, by graphic records, and
by instrumental measurement of the arte-
rial pressure. By far the most important
of these methods is the first. There is a
tendency to exalt the others at the expense
of the digital, but no apparatus can ever
replace the trained finger. No doubt the
other methods can give very definite infor-
mation of a limited kind, but in diagnosing

the patient’s condition they should only sup-
plement the digital examination.”

Obviously such an important subject as
the pulse can only be touched on very
sketchily at this time. Sir William Broad-
bent in 1890 wrote an entire volume on the
pulse, which we can still all read with great
profit. Although in his day the electro-
cardiograph was unknown, it has at least
not unearthed any type of pulse with which
he was unfamiliar. Sir James Mackenzie
in 1902 established his reputation instantly
by the publication of his book, “The Study
of the Pulse.” This classic work was writ-
ten to answer the question of the patients
with an irregularity of the heart who con-
stantly asked Mackenzie, “Doctor, what is
going to happen to me?” Three types of
irregularities, which he described as the
youthful type, the adult type, and the dan-
gerous type, still remain as the three out-
standing varieties of cardiac irregularities
which physicians encounter. Differentia-
tion of these three types by Mackenzie al-
lowed him to answer the patients’ question
as to what was going to happen to them.
The youthful type of irregularity, which we
call today sinus arrhythmia, he told his pa-
tients was harmless, and the many patients
of this class who had previously been
treated for serious heart disease were told
to get out of their beds, forget their hearts,
and go on about their business. His advice
is still sound.

The second group he called adult irregu-
larities, which we call today extrasystoles
or, more accurately, premature contrac-
tions. He told patients with this irregu-
larity that they were not incapacitated by
the irregularity itself. While he recognized,
as we do today, that patients with serious
heart disease often show extrasystoles, he
pointed out that the prognosis depended,
not upon the extrasystoles, but on the con-
dition of the patient’s heart muscle.

The third group of irregularities, which
Mackenzie called the dangerous type of ir-
regularity and we call today auricular
fibrillation, form a rather different cate-
gory. To the families of these patients he
gave, invariably, a very grave prognosis.

54

Major — Instruments of Precision

With the thirty years more experience with
these types of irregularities than Mackenzie
had at the time he published his volume on
the pulse, we now know that transient fi-
brillation occurs in some patients who make
a perfect recovery. But these and similar
observations are only occasional exceptions
to the rule that Mackenzie laid down.

Sinus arrhythmia is readily recognized
by feeling the pulse, the heart rate being
invariably increased on inspiration and de-
creased during expiration. Extrasystoles
are only the “dropped beats” of the older
authors. In auricular fibrillation the “pul-
sus irregularis perpetuus” of the older writ-
ers expresses most strikingly the impres-
sion the pulse gives the examiner. The
bigeminal pulse, the occurrence of two beats
close together followed by a longer pause,
was first satisfactorily explained by Mac-
kenzie, who showed that two mechanisms
might be involved. In the first instance,
in a heart block, each third auricular beat
failing to pass through produces this phe-
nomenon. The second mechanism, alter-
nating extrasystoles, produces the same
type of pulse. Clinically, the condition is
seen most commonly in patients who have
had too much digitalis, and when they ap-
pear in a cardiac patient it is a warning
that digitalis should be discontinued for
twenty-four hours at least.

The collapsing pulse of aortic insuffi-
ciency is so characteristic that the diagnosis
of this condition can be made by palpating
the pulse. Similarly, the small hard pulse
which rises slowly and falls very slowly is
equally diagnostic of aortic stenosis. The
pulsus alternans, of such grave significance
in myocardial disease, and the dicrotic pulse
so suggestive of typhoid fever can be easily
perceived by palpation. The bigeminal
pulse, in which we feel two beats followed
by a pause and then two more beats, is a
common finding in patients who have taken
too much digitalis. When a physician has
been giving a patient digitalis for a time
and feels this type of pulse, it is a warning
to him to discontinue therapy — and a warn-
ing which is just as unmistakable as that
shown by an electrocardiogram. Among

other palpatory findings of great diagnostic
importance are the presystolic thrill of mi-
tral stenosis, the rasping systolic thrill of
aortic and pulmonary stenosis, and the dias-
tolic shock of an aortic aneurysm. These
findings are all just as important and as
certain as anything in medicine.

Percussion of the heart always repays the
effort expended. Percussion of the heart
demonstrates cardiac enlargement far bet-
ter than a study of axis deviation in the
electrocardiogram. The displacement of the
heart to either side can usually be as ac-
curately demonstrated by percussion as by
the x-ray.

Ausculation of the heart has led many
great men astray. Laennec, the father of
auscultation, in the first edition of his work
in 1819, stated that cardiac murmurs were
always produced by valvular lesions, and
added that “their situation and the time at
which they are heard, indicates obviously
which orifice is affected.” Seven years lat-
er, in the second edition of his book, he was
wiser. He had made many diagnoses of
valvular lesions in patients who at autopsy
had shown normal heart valves. This led
him to deny any value whatever to auscul-
tation of the heart, and, as Potain remarks,
he fell into a second error, greater than the
first. Every physician practicing medicine
is constantly puzzled to know whether or
not a heart murmur is of any significance.

Certain murmurs leave no doubt as to
their significance. The presystolic rumble
of mitral stenosis accompanied by a presys-
tolic thrill is one of the most clean-cut find-
ings in clinical medicine. Similarly, a soft
diastolic murmur of aortic insufficiency ac-
companied by a Corrigan pulse leaves little
doubt as to its significance. There are a
few other rare murmurs, as in aortic steno-
sis and pulmonary stenosis, which are rare-
ly encountered, but when they are heard
permit no doubt as to their significance.
But, aside from these classic examples there
are a great variety of murmurs heard at
different parts of the heart, usually systolic
in time, and which are extremely common.
Their significance is usually determined by
repeated auscultation combined with obser-

Major— Instruments of Precision

55

vations on the clinical course of the patient,
not by resort to instruments of precision.

Auscultation of the heart, we should not
forget, gives better evidence for the diag-
nosis of mitral stenosis, of aortic insuffi-
ciency and of the less common lesions than
does any instrument of precision. Gallop
rhythm is well described as a cry of the
heart for help. It is a cry that is heard
only with the stethoscope. Pericardial fric-
tions, machine murmurs, the Duroziez mur-
mur, and the Flint murmur, are all phe-
nomena that are heard.

Physical examination is also of great
value in certain other heart conditions
which are sometimes considered the exclu-
sive preserve of the electrocardiogram. I
refer particularly to bundle branch block
and coronary occlusion. The diagnosis of
bundle branch block can be positively made
in many cases only with the electrocardio-
gram. I should prefer to confirm a tenta-
tive diagnosis with an electrocardiogram.
In the case of coronary occlusion, however,
conditions may be quite different. In many
cases the history, the type of pain, a local-
ized area of pericardial friction, and leuko-
cytosis, make the diagnosis fairly certain.
If it is convenient to obtain an electrocardio-
gram on such a patient, it should be done;
and if it can be brought to the bedside with-
out a great expenditure of energy, and mon-
ey, the electrocardiogram should be taken.
However, I have on more than one occasion
seen a patient transported to the electro-
cardiograph at some risk to his physical
condition, where it would have been far bet-
ter to have left him alone than to have sub-
jected him to further danger for the pur-
pose of confirming a diagnosis already fair-
ly certain. It should also be remembered
that there are silent areas of the heart in
which lesions do not give any characteris-
tic electrocardiogram when taken in the
usual fashion.

The above remarks are not to be con-
strued as disparaging the electrocardio-
graph as an instrument. Dr. S. A. Levine,
of Boston, who certainly has no reason to
be critical of electrocardiography, says :
“An able clinician who knows nothing about

the string galvanometer, can still do better
work than an expert in electrocardiography
who has limited bedside experience and in-
adequate clinical judgment.”

In the diagnosis of the anemias and the
leukemias, a blood count is usually decisive.
The blood counting apparatus is a simple
one which is inexpensive and can be easily
mastered. Much additional information of
value can, however, be obtained by meth-
ods even simpler than blood counts. The
absence of free hydrochloric acid in the gas-
tric juice of patients suffering from perni-
cious anemia is, of course, one of the car-
dinal signs of that disease. Similarly the
physician hesitates to diagnose lymphatic
leukemia without the enlargement of the
lymph glands. In cases of bleeding, a gross
examination of the blood will distinguish
between hemophilia and thrombopenic pur-
pura. If the blood is collected in a small
test tube, the clot of the hemophilic blood
is normal in appearance showing character-
istic retraction, while the clot in thrombo-
penic purpura does not retract at all.

Diabetes is a disease, the knowledge of
which is in a great measure due to exact
laboratory procedure. Much of the infor-
mation we have could have been obtained
in no other way. Yet it is a mistake to
think that extremely technical procedures
are absolutely necessary for the diagnosis
and treatment of a diabetic patient.

The glucose tolerance test, which may be
regarded as an exact laboratory procedure,
is of great aid in an exceptional case which
has been long considered a case of diabetes
mellitus, but does not behave as such. In
such instances, however, the history should
give us the clue and then the test can be
carried out in a well-equipped laboratory.
The routine of carrying out a glucose toler-
ance test in every patient with glycosuria
is an absolute waste of time, unless the phy-
sician is studying some scientific problem
connected with sugar metabolism. In most
diabetics the history and the demonstration
of sugar in the urine clinches the diagnosis.
If the blood sugar is high, especially two
hours after meals, the diagnosis is fairly
certain.

56

Major — Instruments of Precision

There is one striking phenomenon which
is extraordinarily common in diabetics,
which cannot be demonstrated by any in-
strument of precision. I refer to the ace-
tone bi’eath. The ability to smell this pe-
culiar sweetish odor of the breath seems to
vary with different physicians but is cer-
tainly present in a marked degree to most
people. The presence of such a breath in an
individual who shows sugar in the urine
is rather conclusive evidence that he has
diabetes mellitus.

Incidentally, I often wonder if our sense
of smell has not undergone considerable
atrophy. Jonathan Swift, during his resi-
dence in London, wrote a friend that he had
a lodging in Bury Street with “a thousand
stinks in it.” Even allowing for poetic li-
cense and admitting that London in the
early eighteenth century was an unrivalled
training ground for the olfactory nerves,
yet we do seem to have forgotten that cer-
tain diseases emit distinctive odors. All of
us are familiar with the odor of pulmonary
gangrene and of a colon bacillus abscess. It
should be remembered, however, that sev-
eral generations of physicians have de-
scribed the mousy odor in typhus, the sweet-
ish fetid odor of measles, the acid sweaty
smell of rheumatic fever and the odors
characteristic, but difficult to describe, of
diphtheria and smallpox.

The more the physician treats diabetes,
the less frequently does he have blood sugar
determinations made on patients. They
are often of value, but the urine examina-
tion is both simpler and more important.
It is more important to know whether a pa-
tient is secreting sugar during a twenty-
four hour period and, if so, how much, than
it is to know the exact height of his blood
sugar at the precise moment that the blood
is drawn. It cannot be emphasized too
strongly that the blood sugar has constant,
probably minute, variations. A patient may
have a high blood sugar every afternoon,
and a low or normal blood sugar in the
morning before breakfast. In such a pa-
tient, if we were to rely entirely on the
height of the blood sugar before breakfast,
we should think everything was going along

nicely. When, however, we examine the
twenty-four hour specimen of urine, and
should find sugar in it we would know that
all is not as well as it seems. Woodyatt
showed, many years ago, that it was pos-
sible to treat a patient in diabetic coma and
rescue him by examining only the urine.

During the past fifteen years, I have seen
many diabetic patients Who were terribly
disturbed because they had a high blood
sugar and showed no sugar in the urine.
The knowledge that they had a high blood
sugar was a very depressing factor in their
illness. Such patients often show blood
sugar from 200 to 300 every morning and
yet never show sugar in the urine. Next
to insulin, the best treatment for these pa-
tients is the avoidance of blood sugar deter-
minations.

In diseases of the kidney and so-called
essential hypertension, blood chemistry
studies and delicate functional tests have
greatly increased our knowledge of these
diseases. They have not, however, funda-
mentally altered the treatment or made an-
tiquated our methods of diagnosis. In spite
of repeated attempts to estimate kidney
function by means of a variety of tests, we
cannot diagnose a failing kidney until three-
fourths of the glomeruli have been de-
stroyed. In the diagnosis of diseases of the
kidney the sheet anchors are still the sphy-
gmomanometer and the examination of the
urine for albumin and casts. In that in-
teresting disease, known as lipoid nephrosis,
these examinations alone are usually suffi-
cient for the diagnosis. Such patients, in
spite of marked albuminuria and edema,
show a normal blood pressure and a heart
of normal size.

The examination of the stools is becom-
ing a lost art, possibly because the physician
of today finds the procedure rather dis-
agreeable and imagines that other methods
of examining will make up for his negli-
gence in this respect. It should not be for-
gotten, however, that clay-colored stools
still signify obstruction of the bile duct,
tarry stools indicate hemorrhage into the
gastrointestinal tract, and that bulky,

Major — Instruments of Precision

57

foamy stools still suggest pancreatic dis-
ease.

In 1903 John B. Murphy wrote the fol-
lowing sentences :

“The most characteristic and constant
sign of gallbladder hypersensitiveness is
the inability of the patient to take a full,
deep inspiration when the physician’s fin-
gers are hooked up deep beneath the right
costal arch below the hepatic margin. The
diaphragm forces the liver down until the
sensitive gallbladder reaches the examining
fingers, when the inspiration suddenly
ceases as though it had been shut off. I
have never found this sign absent in a cal-
culous or infectious case of gallbladder, or
duct disease.”

This is just as true today as when he
wrote it. It is still true that the majority
of the patients having gall stones that give
any trouble have tenderness on pressure of
the gallbladder. If this tenderness is ab-
sent, or has never been present, we may
question the necessity of operation, even if
the x-ray has demonstrated gall stones.

Palpation and percussion of the abdomen
still remain the safest methods of demon-
strating enlargement of the liver and the
spleen. Demonstration of such enlargement
is often of primary importance in diagnosis.
Palpation of the abdomen still demonstrates
the presence of fluid in the abdomen, just
as surely as it ever did. Abdominal palpa-
tion continues the most important method
of examination in case of suspected appen-
dicitis. In this latter condition even the
roentgenologist cannot venture to tread,
and if he does, probably wishes he had not.
Various abdominal tumors, tumors of the
uterus and the ovary and of the rectum,
are still and probably always will be diag-
nosed by palpation.

These remarks that I have made on the
subject, “Diagnosing Disease Without In-
struments of Precision,” do not, I wish to
emphasize anew, carry with them any slur
upon these instruments. Personally, I em-
ploy them every day in my practice. Thou-
sands of physicians do the same.

It is always important to recognize the

limits of both physical examinations and
instruments of precision.

A colleague of mine a few years ago was
very much incensed at the basal metabolic
apparatus because it did not tell him which
thyroid patients were going to survive oper-
ation and which were not; and he was
threatening to give up its use altogether.
I finally persuaded him not to, by pointing
out that the basal metabolic apparatus was
not a surgical oracle which answered ques-
tions of surgical mortality, but simply an
apparatus to do what it was intended to
do, namely, to estimate the basal metabolism
and nothing else.

There is a great tendency at the present
time in medicine to exalt what seems exact,
and to cry down what is obviously inexact.
No one, however, appreciates the errors and
inexactitude of instruments of precision
more than those who work much with them.
Medicine, we all know, in spite of great ad-
vances, is not a very exact science and prob-
ably will never be. Although when com-
pared with psychology or with psychoanaly-
sis it may seem extremely exact, yet it is
very inexact compared with such sciences
as mathematics, and even physics and chem-
istry. The thought I wish to emphasize is
that correct diagnosis is the sum total of
all the evidence at hand, and is not, as a
rule, obtained from any one method of pro-
cedure, even when instruments of precision
are employed. Instruments of precision are
very desirable and at times very necessary,
but thousands of correct diagnoses are made
daily and hundreds of thousands of patients
are healed without their employment.

During the present emergency we should
cultivate, as students and practitioners,
simple methods of diagnosis. We cannot
be sure that we will always have with us,
on land, on sea and in the air, the electro-
cardiograph, the x-ray and the chemical
laboratory. We can, however, be reason-
ably sure that while we function as physi-
cians, we will be in possession of our five
senses. Under such conditions we will rea-
lize our helplessness if we have leaned too
heavily on instruments of precision in mak-
ing our diagnoses.

58

Ramirez — Test for Poliomyelitis

CLINICAL EVALUATION OF AN
INTRADERMAL TEST FOR
POLIOMYELITIS

CARLOS RAMIREZ, M. D.f *

New Orleans

We lack any specific diagnostic and prac-
tical test for poliomyelitis in any stage of
the disease; such a test would be of in-
estimable value, particularly in the early
phases, when accurate diagnosis is of ut-
most importance. Armstrong, in a sympo-
sium presented at Vanderbilt University in
1941, stated: “In spite of repeated trials
employing the virus of poliomyelitis, no
specific diagnostic test of value has been
evolved.”

The etiologic agent of poliomyelitis is now
generally recognized as a virus. It was
not until 1908-1909 that Landsteiner and
Popper3- 1 succeeded in transmitting the
disease to monkeys by means of an emulsion
of spinal cord obtained from a patient who
had died of this disease. The emulsion was
sterile to the common culture media for
micro-organisms. The disease produced in
the monkey was similar clinically and path-
ologically to human poliomyelitis.

Etiologic agents other than the virus have
been suspected, such as the globoid bodies
of Flexner and Noguchi'1 and the strepto-
cocci of Mathers.6 However, the virus
theory seems most tenable and has been
more intensively investigated.

In 1916, Rosenow1 published a prelimi-
nary report on the isolation of pleomorphic
cocci related to the etiology of poliomyelitis,
and in 1918 he concluded: “. . . The organ-
ism here described bears etiologic relation-
ship to poliomyelitis.”

In 1935 and 1936, Foshay7- 8 described a
skin reaction obtained with specific anti-
serum corresponding to the infectious dis-
ease of the patient. When approximately
0.03 c. c. of a specific antiserum is injected
into the skin of a patient suffering from the
corresponding disease, an erythematous and

* Commonwealth Fellow in Communicable Dis-
eases.

fFrom the Department of Pediatrics, Tulane
University School of Medicine and the Isolation
Unit, Charity Hospital, New Orleans, Louisiana.

often an edematous reaction is produced,
beginning within two to four minutes and
reaching its maximum in fifteen to twenty
minutes. Foshay differentiated his specific
reaction, which he called “E-E reaction”,
trom hypersensitivity to horse serum by
the following features: (1) Only the spe-
cific horse serum against the correspond-
ing disease elicited an early erythema, often
with edema; (2) the erythema of the so-
called “E-E reaction” appears very prompt-
ly, in two to four minutes after injection,
and fades sooner than the urticaria pro-
duced by normal horse serum in cases of
hypersensitivity. The erythema of the “E-
E reaction” does not itch and has no pseudo-
podiae; (3) when patients with the “E-E
reaction” and negative hypersensitivity to
normal horse serum were given specific
serum intravenously, no untoward reactions
were observed and further, the “E-E reac-
tion’ often could not be reproduced later in
the same patient.

Foshay explained these particular skin
tests as being due to specific antigen-anti-
body reactions in the skin. The bacterial
antigen is circulating freely during the
acute phase of the disease and is therefore
present in the skin; when antiserum is in-
jected into the skin, the antigen-antibody
mixture produces a reaction. He studied
the test in many infectious diseases, but
principally in tularemia and brucellosis. Ta-
mura" soon reported similar studies in
lymphogranuloma inguinale.

In 1937, Rosenow10- 11 applied Foshay’s
skin testing procedure to poliomyelitis,
using his own poliomyelitis antistrepto-
coccic serum : “The cutaneous test is made
by injecting superficially into the epidermis
approximately 0.03 c. c. of a 10 per cent
saline solution of the wet, centrifuged
euglobulin from the serum of horses hyper-
immunized to the streptococcus. If the re-
sults of the test are positive, an erythema-
tous-edematous reaction occurs almost im-
mediately, which reaches its maximum
usually in ten minutes. The area of the re-
action is calculated in square centimeters.
A greater reaction to the poliomyelitis anti-
streptococcus than to other antistrepto-

Ramirez — Test for Poliomyelitis

59

coccic serums and normal horse serum is
considered positive and indicative of an in-
fection by streptococci antigenically related
to the streptococcus of poliomyelitis.” Rose-
now1246 later published several articles con-
firming his earlier report.

Having explained the type of skin test
employed, I shall describe the technic and

TABLE I

SKIN TESTS IN POLIOMYELITIS

J. T.

5 yr.

19 days

12.25

2.25

+

3 mo.

15.7

3

+

N. S.

6yr.

8 days

9

0.25

+

3 mo.

6

3

7

K. C.

8 yr.

2 yr.

9

9

0

P. P.

2 yr.

20 days

12.25

1

4-

G. M.

3 yr.

49 days

4

0.36

+

C. J.

5 yr.

3 yr.

5.7

0

+

E. B.

22 mo.

51 days

2.25

0

—

J. S.

7 yr.

26 days

9

4

+

3 mo.

6

2.25

.+

W. P.

8 yr.

7 days

12

8.75

0

2 mo.

2.25

4

-

M. K.

2 yr.

13 days

7.5

1.5

+

41 days

6.25

0

+

G. C.

8 yr.

4 days

1.5

3

-

34 days

7.5

6.25

0

F. C.

2 yr.

22 days

4

2.25

0

Y. A.

7 yr.

18 days

19.25

7.5

+

69 days

7.5

2.25

+

J. L.

17 mo.

39 days

12

6.25

0

3 mo.

9

7.25

0

B. T.

16 yr.

2 mo.

18

32

0

113 days

12

17.5

0

S. M.

4 yr.

21 days

6.25

0

+

73 days

4

0

+

C. T.

12 yr.

39 days

11.25

6.25

0

P. T.

2 yr.

64 days

12

3

+

117 days

7.50

2.5

+

M. G.

6 mo.

32 days

9

7.5

0

84 days

6

3

?

B. W.

15 yr.

52 days

14

16

0

92 days

20

35

0

C. C.

9 yr.

17 days

6

0

+

57 days

6

4

0

N. L.

14 mo.

15 days

6.25

1

+

55 days

6.25

0

+

*+ positive. — negative. ? doubtful. 0 useless.
37 reactions:

Resume

(for cases with poliomyelitis)

Useless and negative:

16

(43.2%)

Positive :

19

(51.9%)

Doubtful :

2

( 4.9%)

13 (21 days or less)

Useless and negative:

5

(38.4%)

Positive :

8

(61.6%)

24 (more than 21 days)

Useless and negative:

13

(54.1%)

Positive :

9

(37.5%)

Doubtful :

2

( 8.4%)

22 Patients

Negative :

9

(40.9%)

Positive :

10

(45.0%)

Doubtful :

3

( 4.1%)

results. The material* consisted of: (1) a
10 per cent solution of euglobulin in saline
from the serum of horses which had been
hyperimmunized against the poliomyelitis
strain of streptococci; (2) normal horse
serum similarly diluted. Approximately
0.05 c. c. of the 1:10 dilution of euglobulin
was injected intradermally into the upper
part of the forearm and an equal amount
of dilute normal horse serum into the lower
part. The test was read in ten minutes.
The maximal diameters of erythema were
measured and evaluated in square centi-
meters. The reactions were classified in
the following manner. A positive reaction
was one whose erythematous area was
greater than 3 sq. cm. and whose control
showed less than one-half this area. A
negative test was one in which the area of
erythema measured less than 3 sq. cm. A
doubtful test was one in which the area of
erythema was 3 sq. cm. or more but the
control site showed half as much reaction.
A useless test was one in which the area
of erythema was greater than 3 sq. cm. but
whose control was larger than half this
area.

Twenty-one cases of typical poliomyelitis
were tested, with a total of 37 reactions
(table 1). Sixteen reactions, or 43.2 per
cent, were useless or negative (13 useless
and three negative) 19, or 51.9 per cent,
were positive; and two, or 4.9 per cent,
were doubtful. Thirteen of the 37 tests
were made within 21 days of the onset of

♦Furnished through the courtesy of Eli Lilly and
Company.

60

Ramirez — Test for Poliomyelitis

the disease; five (38.4 per cent) of these
were useless or negative and eight (61.6
per cent) were positive. Of the 24 tests
done after 21 days following the onset, 13
(54.1 per cent) were useless or negative,
nine (37.5 per cent) were positive, and two
(8.4 per cent) were doubtful.

Seventeen tests were done in 16 patients
with various other infectious diseases (ta-
ble 2) ; seven (41.8 per cent) of these were

TABLE III

SKIN TESTS IN NORMAL CONTROLS

TABLE II

SKIN TESTS IN MISCELLANEOUS CONDITIONS

J. w.

3 yr.

13 days

8

4.5

0

D. E.

4 yr.

3 days

4.5

1

+

J. H. M.

11 mo.

57 days

8

8

0

J. T.

15 yr.

2 days

17.50

0

+

J. C.

19 mo.

12 days

5

1

+

H. P.

32 yr.

7 days

6

3

7

L. M.

9 yr.

8 days

12

6

9

B. B.

10 yr.

18 days

9

4

+

E. R.

10 yr.

4 days

9

2.25

+

S. P.

53 yr.

12

15

0

I. W.

40 yr.

3 days

12.25

14

0

I. W.

10 yr.

3 days

14

1.5

+

M. W.

10 yr.

7 days

7.5

14

0

N. W.

2 yr.

7 days

14

12.5

0

H. B.

7 yr.

26 days

8.75

0

+

79 days

22.5

22.5

—

C. B.

3 yr.

36 days

12.25

2.25

-f-

Resume

17 reactions, 16 cases:

Useless: 7 cases (41.2%)

Positive: 8 cases (47.0%)

Doubtful: 2 cases (11.8%)

A. Babies 6 months to 2 years with no history
of previous disease

Reaction (sq. cm.)

Patient

Test

Control Interpretation

L. R.

5

1.44

+

O. P.

6

2.25

+

G. A.

5

3

0

S. J.

14

5

+

D. R.

9

3

+

L. L.

10.50

5

S. D.

7.50

3

+

F. J.

10.50

1.50

+

B. Healthy medical students : no history

of

poliomyelitis*

C. R.

7.50

0

4-

E. C.

10

0

+

R. B.

7.70

0

+

N. B.

7.50

0

+

C. B.

13.50

0

+

H. B.

5

0

-f

H. C.

12

0

+

B. B.

15.75

8.75

0

♦Failure to elicit a history of

poliomyelitis

(or known

contact! of

course has little, if

any. value in

excluding

“subclinical

infection" and consequent acquired

immunity.

This feature

of poliomyelitis only

■ serves to reduce further

the diagnostic value of such a

skin test.

TABLE IV

SUMMARY :

EVALUATION OF

SKIN TESTS

CARRIED

OUT IN THIS

STUDY

Negative
or Useless
Per cent

Positive
Per cent

Doubtful
Per cent

Poliomyelitis

43.2

51.9

4.9

Under 21 days

38.4

61.6

Over 21 days

54.1

37.5

8.4

Miscellaneous Diseases
“Normals”

41.2

47.0

11.8

Well babies

12.5

87.5

Medical students

12.5

87.5

useless, eight (47 per cent) were positive,
and two (11.8 per cent) were doubtful. Of
the 16 normal controls (table 3), 14 (87.5
per cent) were positive and eight (12.5 per
cent) were useless.

On the basis of this study, it seems ap-
parent that Rosenow’s skin test for polio-
myelitis has no positive diagnostic value
and that the negative reaction is not re-
liable for the exclusion of poliomyelitis.

poliomyelitis with the poliomyelitis anti-
streptococcic serum. Although the number
of cases studied is relatively small and will
require further additions at a later date, it
appears that the test lacks specificity and
therefore has little if any diagnostic value.

REFERENCES

SUMMARY

This paper deals with an evaluation of
Rosenow’s experiments on skin testing for

1. Rosenow, E. C., Towne, E. B., and Wheeler, G. W. :
The etiology of epidemic poliomyelitis : preliminary report,
,T. A. M. A., 67 :1202, 1910.

2. Rosenow, E. C.. and Wheeler, G. W. : Etiology of
epidemic poliomyelitis, J. Infect. Dis., 22 :281, 1918.

3. Landsteiner, K., and Popper, E. : Mikrosckpische
praparate von einen mensclilichen und zewi affenrucken
mar ken, Wien Klin. Schnschr.. 21 :1830, 1908.

4. Landsteiner, K„ and Popper, E. : Ubertragung der

Ramirez — Test for Poliomyelitis

61

mliomyelitis acuta auf affen, Ztschr. f. iramunitatsforscli
l. exper. Therap., Orig'., 2 :377, 1909.

5. Flexner, S.. and Noguchi, H. : Experiments on the
■ultivation of the virus of poliomyelitis, J. A. M. A.,
iO :362, 1913.

6. Mathers, G. : Some bacteriologic observations on

■pidemic poliomyelitis, J. A. M. A., 67 :1019, 1916.

7. Foshay, Lee : Intradermal antiserum tests : A bac-
erial-specific response not dependent upon serum sensi-
:ization but often confused with it, J. Allergy, 6 :360,
.935.

8. Foshay, Lee : The nature of the bacterial-specific
ntradermal antiserum reaction, J. Infect. Dis., 59 :330,
.936.

9. Tamara, J. T. : Rapid presumptive diagnosis of

ymphogranuloma inguinale : a specific intradermal test
vith antilympbogranuloma inguinale goat serum, J. Lab.
ind Clin. Md., 21 :842, 1936.

10. Heilman, F. R., and Rosenow, E. C. : Newer meth-
>ds of study and treatment of chronic streptococcal dis-
use, Proc. Staff Meet. Mayo Clin., 12 :252, 1937.

11. Rosenow, E. C. : Precipitin and cutaneous strepto-
;oecal antibody-antigen reactions in poliomyelitis, Proc.
Staff Meet. Mayo Clin, 12 :531, 1937.

12. Rosenow, E. C. : The early diagnosis and treat-
nent. of poliomyelitis with poliomyelitis antistreptococci
serum, 111., Med. J., 76 :144, 1939.

13. Rosenow, E. C. : Application of a cutaneous test
n relation to acute sporadic and epidemic poliomyelitis,
Proc. Staff Meet. Mayo Clin., 14 :734, 1939.

14. Rosenow, E. C. : Specific streptococcal antibody-
intigen reaction of the skin and serum of monkeys during
ittacks of experimental poliomyelitis, Proc. Staff Meet.
Mayo Clin., 15 :382, 1940.

lo. Rosenow, E. C. : A diagnostic cutaneous reaction in
lcute poliomyelitis, Proc. Staff Meet. Mayo Clin., 18 :118,
1943.

16. Rosenow, E. C. : Streptococcic antibody-antigen re-
ictions of the serum and skin of monkeys during attacks
)f experimental poliomyelitis, Proc. Staff Meet. Mayo
Clin., 18 :205, 1943.

0

PNEUMOPERITONEUM IN THE
TREATMENT OF PULMONARY
TUBERCULOSIS

REPORT OF A PATIENT SUCCESSFULLY
TREATED

B. M. STUART, M. D.f

R. L. PULLEN, M. D.f
AND

J. L. WILSON, M. D.f

New Orleans

Pneumoperitoneum has been used since
;he turn of the century in the treatment of
tuberculous enteritis and peritonitis and
as an aid in gynecologic diagnosis. How-
ever, no mention was made in the literature
of its use in treating pulmonary tuberculosis
until 1930 when Vadja1 first reported the
use of pneumoperitoneum to elevate the dia-
phragms of patients with pulmonary tuber-

fFrom the Department of Medicine, Tulane
University of Louisiana School of Medicine, and
Charity Hospital of Louisiana at New Orleans.

culosis. Since that time, many work-
ers2’ 3’ 4 have observed the use of pneumo-
peritoneum alone as well as a supplementary
measure in patients with phrenic paraly-
sis.5’ °- 7’ 8 More recently, the use of pneu-
moperitoneum to supplement successive bi-
lateral phrenicectomy has been reported.9

Though defined poorly, several generally
accepted indications for pneumoperitoneum
in the treatment of pulmonary tuberculosis
are: (1) bilateral tuberculosis that has not
responded to other forms of conservative
treatment such as pneumothorax or phrenic
nerve interruption; (2) pulmonary hemor-
rhage not controlled by other methods;
(3) pulmonary tuberculosis considered
too extensive for bilateral pneumothorax
or other collapse therapy; (4) adjunctive
therapy in those patients in whom pneumo-
thorax has been abandoned, the lung has
re-expanded, and additional treatment is
considered advisable; (5) to supplement in-
terruption of the phrenic nerve; and (6)
palliative treatment for far advanced cases.

The rationale of pneumoperitoneum in the
treatment of pulmonary tuberculosis is
based upon the following changes that have
been observed: (1) lymph stasis and sub-
sequent fibrosis of the lung parenchyma;

(2) pulmonary congestion resulting in
anoxemia unfavorable for the growth and
dissemination of the aerobic tubercle bacilli;

(3) reduction in chest capacity amounting
to 15 to 35 per cent resulting from the de-
creased vertical length of the lung;10 (4)
decreased movement and relaxation of dis-
eased tissues favoring collapse of tubercu-
lous cavities and exudative lesions; and (5)
diminution of the toxic manifestations of
the disease as a result of more effective
pulmonary drainage.

As a method of treatment of pulmonary
tuberculosis, pneumoperitoneum possesses
certain advantages : (1) pneumoperitoneum
is reversible and may be discontinued at any
time; (2) pulmonary relaxation is gradual
so that sudden reduction of vital capacity
does not occur; (3) some relaxation or
“splinting” of the good lung occurs which
may diminish contralateral bronchogenic
spread of the disease ; and (4) coughing and

62

Stuart, Pullen and Wilson — Pneumoperitoneum

expectoration are facilitated. However, the
following complications have been observed
following pneumoperitoneum : air embo-

lism; 7- 11 peritoneal effusion;10 mediastinal
emphysema ; perforation of the diaphragm
and resulting pneumothorax ;12 scrotal
pneumocele ; and hemorrhage from the deep
epigastric artery and other blood vessels.
As a result, the following contraindications
to pneumoperitoneum are accepted general-
ly: (1) diaphragm fixed with adhesions on
the diseased side; (2) coronary artery dis-
ease; (3) amyloidosis; (4) cardiac decom-
pensation; (5) generalized arteriosclerosis;
and (6) failure to try first the standard
procedures of collapsing the lung when
these procedures are not contraindicated.

That pneumoperitoneum does not effect
any untoward local pathologic responses has
been substantiated by autopsy studies13 re-
vealing no reaction of the peritoneum in 75
per cent and low grade inflammatory
changes possibly due to the pneumoperi-
toneum in only 10 per cent. Ascites was
observed usually in those patients with tu-
berculous peritonitis. With increasing du-
ration of therapy, however, a tendency for
gradual thickening of the peritoneum was
noticed.

The authors employ the following technic
for pneumoperitoneum : A point on the an-
terior abdominal wall 4 or 5 cm. below the
umbilicus and just lateral to the rectus
muscle is selected, prepared in the usual
manner, and anesthetized with 1 per cent
procaine solution. A 22-gauge infiltration
needle may be used for anesthetization of
the peritoneum. For the injection of the air
an ordinary pneumothorax needle is satis-
factory. It is desirable to attach this needle
to a 2 c. c. syringe partially filled with pro-
caine solution for insertion into the ab-
dominal wall. As soon as the needle is in-
troduced into the peritoneal cavity, the
fluid in the syringe flows freely into the
peritoneal cavity, and this phenomenon in-
dicates to the operator that the peritoneal
cavity has been gained. A standard pneu-
mothorax apparatus with manometer is
then connected to the needle. Ordinarily no
manometer readings are possible at this

time until considerable air has been in- '
jected. If a sudden positive pressure fol-
lowing the injection of a few cubic centi-
meters of air is observed, the needle prob-
ably has not penetrated the peritoneum. The
authors usually introduce 500 to 1,000 c. c.
of air on the initial injection. The amount
of air and the frequency of injections must,
however, be adapted to the individual case.

The authors have observed certain, rather
constant clinical features following pneu-
moperitoneum : sense of fullness or tight-
ness in the epigastrium ; dull, aching pain in
one or both shoulders and in the back of the
neck; disappearance of the liver dulness «
to percussion; and diminished capacity for
food.

Electrocardiographic changes following
pneumoperitoneum have been reported by
Elwood, Piltz and Potter10 to include devia-
tion of electrical axis to the left with eleva-
tion of both hemidiaphragms without phren-
ic paralysis. Changes in those patients
with right phrenic nerve block in addition
to the pneumoperitoneum resulted in devia-
tion of the electrical axis to the right, with
definite decrease in any left axis deviation
which may have been present previously.
Electrocardiographic studies on patients
with left phrenicectomy in addition to pneu-
moperitoneum revealed marked left axis
deviation particularly if the phrenic nerve
interruption resulted in considerable rise of
the diaphragm. After resorption of air and
regeneration of the nerves, the anatomic
and electrical axes of the heart were re-
stored.

CASE REPORT

This 26 year old, white female was admitted to
the tuberculosis unit of Charity Hospital on Feb- ;
ruary 24, 1940, complaining of a persistent cough
for five months which was relatively non-produc-
tive. Physical examination revealed a well nour-
ished, well developed white woman of the stated
age. The only pertinent findings were rales in
both apices, more predominant on the left. Labora- 1
tory data revealed a sedimentation rate of 24 mm.
in one hour (normal 18 mm.), 12,200 white blood
cells, of which the differential smear disclosed 70
per cent polymorphonuclear leukocytes, 28 per
cent lymphocytes, 2 per cent monocytes. Hemo-
globin was 80 per cent of normal. Blood serology
was negative. Urinalysis was negative. Intra-

Stuart, Pullen and Wilson — Pneumoperitoneum

63

dermal tuberculin test was positive to 1:10,000 0.
T. The sputum was negative for tubercle bacilli
but they were found in the gastric washings. Vital
capacity was 1,600 c. c. A roentgenogram of the
chest (fig. 1) was made on March 4, 1940, which
showed a clearly outlined cavity 3.5 cm. in diam-
eter just beneath the left clavicle with some sur-
rounding infiltration and a small amount of infil-
tration in the first and second interspaces an-
teriorly on the right side. Left pneumothorax was
attempted unsuccessfully on the left side on March
14, 1940. On March 26, 1940, the left phrenic
nerve was crushed. On April 17, 1940, the vital
capacity measured 1,350 c. c. Fluoroscopic exami-
nation revealed that the left diaphragm was mo-
tionless and that no appreciable rise had been ob-
tained. The cavity persisted. On December 31,
1940, the left phrenic nerve was crushed again.
On May 18, 1941, pneumoperitoneum was initiated,
350 c. c. of air being introduced initially. After
seven refills of 500-1,000 c. c. of air, the patient
was placed on a bimonthly schedule, 1,000-1,500
c. c. of air being given each time. In Febru-
ary of 1942, she was discharged from the hospital.
Treatment was continued in the clinic.

During treatment, the left diaphragm rose to the
third rib anteriorly and the right diaphragm rose
to the fourth interspace anteriorly (fig. 2). The
pneumoperitoneum was abandoned on January 4,
1943, a total of forty-two refills having been given.

Fig. 1. Roentgenogram of patient on admission
to hospital.

Fig. 2. Roentgenogram showing elevation of
both diaphragms by the pneumoperitoneum and
collapse of the cavity in the apex of the left
lung.

At that time, the patient did not produce any
sputum, her weight was stationary, and there
were no clinical symptoms. She was working regu-
larly.

The patient has been seen in the clinic regularly
up to the present date. Although the left dia-
phragm is still slightly elevated, she has had no
clinical symptoms to date. On recent roentgeno-
grams, there is no evidence of cavitation and the
parenchymal involvement has improved remark-
ably (fig. 3).

DISCUSSION

This case has been presented, as evidence
that the treatment of pulmonary tubercu-
losis with pneumoperitoneum supplement-
ing phrenicectomy may be successful. Many
of the cases reported in the literature have
been far advanced cases of pulmonary tu-
berculosis in which pneumoperitoneum was
induced as a palliative procedure in the
terminal stages of the disease. For that
reason pneumoperitoneum has been consid-
ered unfavorably by many as a therapeutic
procedure.

64

Boas — Phenomena of Aging

Fig-. 3. Roentgenogram after the pneumoperi-
toneum had been discontinued. The lungs appear
remarkably clear.

SUMMARY

In unilateral cases of pulmonary tuber-
culosis in which pneumothorax cannot be
instituted, pneumoperitoneum and phrenic
nerve interruption may produce sufficient
immobilization and collapse of the lung to
enable the acute processes to subside. Exu-
dative lesions and thin-walled cavities may
respond satisfactorily to this form of treat-
ment. Such responses may obviate future
surgical procedures such as thoracoplasty.

REFERENCES

1. Vadja, L. : Ztschr. f.%Tuberk, 67:391, 1930.

2. Banyai, A. L. : Therapeutic pneumoperitoneum. Am.
Rev. Tuberc., 29 :603, 1934.

3. McIntyre, J. P. : Artificial pneumoperitoneum ap-
plied to certain therapeutic problems in pulmonary tuber-
culosis, Edinburgh M. J., 47 :688, 1940.

4. Hobby, A. W. : Pneumoperitoneum, J. M. A. Georgia,
28 :160, 1939.

5. Joannides, M., and Schlack, O. C. : Use of phrenic
neurectomy combined with artificial pneumoperitoneum for
collapse of adherent tuberculous lung, J. Thoracic Surg.,
6 :219, 1936.

6. Trimble, H. G., and Waldrip, B. G. : Pneumoperi-
toneum in treatment of pulmonary tuberculosis, Am. Rev.
Tuberc., 36:115, 1937.

7. Fremmel, F. : Pbrenicectomy reinforced by pneumo-
peritoneum, Am. Rev. Tuberc., 36:490, 1937.

8. Banyai. A. I,. : Mechanical effect of artificial pneu-

moperitoneum and phrenic nerve block. Arch. Sure..
38:149, 1939.

9. Bryan, E. C., and Ricen, E. : Surgical treatment of
pulmonary tuberculosis. United States Naval Med. Bull.,
38 :553, 1940.

10. Woodford, L. G. : Pneumoperitoneum with phrenic
paralysis, Dis. of Chest, 8 :298, 1942.

11. Warring, F. C., Jr., and Thomas, R. M. : Spon-
taneous air embolism, Am. Rev. Tuberc., 42 :682, 1940.

12. Mellies, 'C. J. : Pneumoperitoneum (with unusual
complication), J. Missouri M. A., 36:431. 1939.

13. Monts, R. W., and Bradford. H. A. : Scrotal pneu-
mocele. Am. Rev. Tuberc, 47 :538, 1943.

14. Banyai, A. L. : Pneumoperitoneum, Dis. of Chest,
3:9, 1937.

15. Trimble, H. G., Eaton, J. L., and Moore, G. : Pneu-
moperitoneum in the treatment of pulmonary tuberculosis
(local effects on peritoneum), Am. Rev. Tuberc, 39:529,
1939.

16. Elwood, B. J., Piltz, G. F., and Potter, B. P. : Elec-
trocardiographic observations on pneumoperitoneum. Am.
Heart J., 19 :206, 1940.

0

THE PHYSIOLOGIC AND CLINICAL
PHENOMENA OF AGING*

ERNST P. BOAS, M. B.

New York City

I am sure that before this audience I
need not elaborate on the growing numbers
of elderly persons in the population of the
United States. Today there are actually
6.000,000 more persons who are 65 years
of age or older in the United States than
there were in 1900 ; and it is estimated that
by 1980 the total number in this age group
will be 22,000,000. With this change in
the age distribution of our patients there
is an accompanying change in the nature
of the diseases from which they suffer. The
increased span of life is due in large meas-
ure to the remarkable diminution in the fre-
quency of infectious diseases. Today the
chronic so-called degenerative diseases are
responsible for three-quarters of all deaths.

Thus it becomes important that we recog-
nize this shift in the phenomena of disease
and equip ourselves to cope with it. These
changes are as significant in preventive
medicine as they are for the treatment of
the sick. In former years the public health
officer confined his activities to sanitation,
mosquito eradication and suppression of
epidemic diseases and mass vaccination.
These methods do not serve in the control

*Read before the Eighth Annual Meeting of the
New Orleans Graduate Medical Assembly, March
6-9, 1944,

Boas — Phenomena of Aging

65

of cancer, heart diseases and rheumatism.
The health officer who is beginning to
undertake responsibility for the control of
some of these chronic diseases is working
out a new approach. He realizes that these
diseases must be recognized in their incipi-
ency, and that complete treatment must be
made available as soon as they are discov-
ered. So he has become interested in health
examinations, in clinics and hospitals where
diagnostic and therapeutic measures can
be carried out. The wiser among the health
officers have recognized that in the control
of these chronic diseases the practicing
physician is the first line of defense, it is
he who must try to keep his patients well,
who must recognize deviations from the
normal at the earliest possible moment, and
who must see to it that proper treatment is
carried out. Certainly for the elderly and
the aged, the general practitioner is the key
health officer of the community.

Treatment of the aged has two aspects —
the treatment of the aging person, and the
treatment of disease in the aged. Treat-
ment of the aging person demands knowl-
edge of the normal processes of senescence,
of the changes in function and structure
that come with the years, and of the manner
in which they modify the potentialities for
living. The diseases that we encounter in
the aged are the same diseases that we see
in younger persons, but often their mani-
festations are somewhat different in the
aged, for the aging body reacts differently
to the noxious processes.

Most of the diseases of the aging organ-
ism are popularly considered and termed
degenerative diseases. This implies that
the disease is due to the gradual wearing
out of the several tissues of the body, that
the disease is in essence evidence of aging;
that it is an inevitable process of senescence.
Were this so, we would have to accept the
invalidism of aging as part of our inescap-
able heritage, and consider medicine as
powerless to halt its progress, or to restore
the worn out dying organism.

The distinction between aging and di-
sease is not a purely academic one. If, for
instance, we regard arteriosclerosis solely

as a phenomenon of aging, a process that
inevitably makes its appearance in the aging
arteries of every person, we may well throw
up our hands in the conviction that treat-
ment is futile, research fruitless. If we re-
gard arteriosclerosis as a disease process,
that manifests itself with particular fre-
quency in older persons, we will strive to
discover its causes and marshall in its
therapy all of the knowledge and methods
that we have at our disposal. There is much
evidence to prove that arteriosclerosis, as
encountered as a cause of disease among our
patients, is not a simple senescent process,
but a pathologic one that may eventually be
brought under control. So it is with many
of the other disabilities of the aged.

It is important to reach a common under-
standing of the nature of the aging process.
Most people think of aging as a terminal
event; as a running down or wearing out
of the organism; as a final tissue and organ
deterioration preceding death. This is an
incorrect concept. Aging is but a part of
the whole cycle of life. Growth, differen-
tiation, involution are but different phases
of the life curve, manifesting themselves at
different rates in different structures of the
body. The milk teeth become loosened and
are cast off in childhood, the thymus gland
atrophies in early life, the ductus arteriosus
closes shortly after birth. Yet these phe-
nomena result from processes no different
from those that cause similar organ changes
in the aged. All of the phenomena of aging
do not appear simultaneously. In the same
individual graying of the hair, far sighted-
ness, loss of elasticity of the skin, or of the
arteries, decalcification of the bones occur
at different ages; and among different in-
dividuals there is the greatest variation in
the time of occurrence of these so-called
stigmata of aging. When we speak of
senescence, and aging of the organism we
arbitrarily segregate the anatomic and
physiologic phenomena observed in older in-
dividuals and assign to them attributes of
degeneration of the organism due to aging.
Aging and death may result from wear and
tear of the organism due to external in-
sults; it may result from the accumulation

66

Boas — Phenomena of Aging

of inhibiting substances within the organ-
ism; it may result from a diminution or
gradual extinction of the original vital
force.

It has been shown experimentally that
each organ and tissue has its own time curve
of aging, and that this time curve depends
on three factors : heredity, the external en-
vironment, and the internal environment of
the body. The most important of these
three elements is heredity. Strains of mice
can be inbred so that aging occurs uni-
formly in all individuals of that strain.
Furthermore, it has been shown that, com-
paring different strains of mice, the ana-
tomic changes occurring in the several or-
gans are strain characteristics in their time
of occurrence, that is, that various organs
age at different rates in different strains of
mice. The same phenomenon is observed
in man. Longevity is primarily a family
characteristic. Early greying of the hair
or early hypertension or coronary artery
sclerosis are family traits. Aging is pri-
marily a constitutional phenomenon heredi-
tarily determined.

It has often been suggested that hor-
mones, particularly the sex hormones, may
control the aging process. Many have
claimed that the menopause marks the first
sign of aging in women and that there is a
similar climacteric in men. Both clinical
and experimental studies give no support
to this view. The menopause is character-
ized by a diminished secretion of estrogens,
and an increase in the urinary gonadotro-
pins, by vasomotor disturbances — the well
known hot flushes, with headache, dizziness,
by psychic changes and by “rheumatic
pains.” Men give no manifestations of a
similar abrupt climacteric. There is no sud-
den decrease in the androgens, although in
the later years of life smaller quantities of
androgens are excreted. Yet some aged men
have a high titer of urinary androgens.
There is no significant elevation of gonado-
tropins in the urine of aging men, nor do
they suffer from hot flushes or other symp-
toms of the menopause. Men who suddenly
lose their testicular function as a result of
castration or disease do undergo a climac-

teric-] ike state. They have vasomotor dis-
turbances, and an increase in urinary
gonadotropins. Experimental studies have
shown that several internal secretory glands
may accelerate or retard the time curves of
involution of various organs but that pri-
marily the effects depend on inherited char-
acteristics. There is no master hormone
controlling senescence.

All structural changes found in the aged
are not signs of senescence. The older the
person, the greater his years of exposure to
external insults, and the greater the possi-
bility that his body will show scars of these
encounters. A generation ago, when tuber-
culosis was far more widespread than it is
today, almost every adult, at autopsy, gave
evidence by the scarring of his lungs that
he had undergone a tuberculous infection.
These scars were not manifestations of
aging, but aged individuals, because of years
of exposure to tuberculous infection, almost
universally had been infected at some time.

Often it is difficult to distinguish between
phenomena of pure senescence and those of
superimposed disease — a disease process
whose development may be favored by the
aging of the tissues. Fractures of the hip,
through the neck of the femur, are very
common in old persons. The bone has be-
come ratified and brittle, the aged person
has lost some of his resiliency, balance and
coordination, so that he falls more easily,
and the weakened bone breaks more readily.
Although aging plays its part, the actual
fracture is an accident, it does not connote
aging. Similar considerations apply to the
so-called hypostatic pneumonias of the aged.
Loss of elasticity of the lungs, rigidity of
the thoracic cage, diminished excursion of
the diaphragm, all presumably favor the
collection of secretion in the lungs and pre-
vent the expulsion of this material when it
becomes infected. The element of infection,
however, is an accident, not a manifestation
of aging.

The human changes most characteristic
of aging, bodily changes that are ac-
cepted, in the popular mind, too, as evidence
of senescence are: loss in height, loss in
weight, presbyopia, deafness for high tones,

Boas — Phenomena of Aging

67

graying of the hair, loss of elasticity of the
skin. None of these alterations of the struc-
ture and texture of the body are regarded
as disease processes, none of them challenge
the continuance of life.

It has repeatedly been pointed out that
natural death, death from natural decay,
or from true senility, occurs very rarely in
man. Autopsies on old people always re-
veal a patholgic cause of death, thought no
symptoms were observable during life. The
most common causes of death in persons
over 65 years of age are : arteriosclerosis of
the coronary, cerebral or peripheral ar-
teries, hypertension, carcinoma of the gas-
trointestinal tract, prostatic hypertrophy,
tuberculosis and street accidents.

Some very practical considerations can
be derived from a contemplation of these
facts. The physician must always be on
the alert to distinguish between disease and
aging in dealing with older patients. He
must not carelessly ascribe their symptoms
and disabilities to the running down of their
bodies. At the same time he must become
fully aware of the physical and mental
changes that take place in the aging organ-
ism, and learn how involutional alterations
in the structure and function, of the body
may affect and alter the manifestations of
disease. The physician diagnoses disease as
it appears in the human body, he is con-
cerned largely with the reaction of the body
to disease. He treats not a disease, but a
sick person.

Disability and illness, no matter at what
age they occur, whether in infancy or in
the ninth decade, must be regarded as re-
sults of disease, a challenge to the diagnos-
tic and therapeutic art of medicine. Only
with such an attitude can knowledge ad-
vance; only with such an approach can we
hope to control and prevent many of the
chronic diseases of advancing years that
are, as yet, incompletely understood.

With increasing age of the organism there
is a progressive dehydration of the tissues
with a reduction of intracellular fluid, the
colloidal systems undergo alterations, elas-
tic tissue loses its elasticity. Some of the
outward manifestations of the underlying

chemical changes in the body contribute to
the characteristic stigmata of aging. Chief
among these are loss of weight and stature.
The back becomes bowed with a gentle
kyphosis. The skin atrophies and becomes
thinned, the subcutaneous fat disappears,
there is loss of elastic tissue, and the skin
becomes dry and wrinkled. There is atrophy
of the hair and sweat follicles. The hair
turns gray and falls out. The teeth become
loosened and are gradually lost.

Changes in the eyes are characteristic.
Diminution of orbital fat leads to enophthal-
mos, loss of tone in the muscles and skin
causes drooping of the eyelids, both fea-
tures combined contributing greatly to the
facies of aged persons. Arcus senilis, al-
though not confined to the aged, is common
in elderly individuals. Finally presbyopia,
loss of accommodation, is one of the most
definite evidences of aging. Careful sta-
tistical study has shown a genuine correla-
tion between the age of onset of presbyopia
and length of life.

Impairment of hearing, particularly for
high tones, begins at age 50 and slowly
progresses. It is due to simple atrophy of
the nerve and the end-organ in the cochlea,
and is an almost universal accompaniment
of aging.

Parallel with these changes that are dis-
cernible by the layman, and that together
constitute the picture of the aged person,
there are analogous changes in the internal
organs.

The changes in structure and function of
the heart and arteries that come with age
are few and simple and do not give rise to
clinical syndromes of disease, nor do they
lead directly to death. The concept is er-
roneous that diseases of the heart and ar-
teries at ages past 50 are inevitable mani-
festations of the aging process, that they
are unavoidable and incurable. The im-
portant senescent changes in the heart are :
pigmentation of the heart muscle fibers,
atrophy of the heart muscle, enlargement of
the valvular ostia and stretching and loss
in elasticity of the valves. The electro-
cardiogram of the aged has no characteris-
tics that distinguish it from that of younger

68

Boas — Phenomena of Aging

persons. There is an increasing tendency
to left axis deviation, an increase in the
relative duration of systole and a lessened
frequency of sinus irregularity. Prolonga-
tion of the PR interval is common. Studies
have shown that about one-quarter of per-
sons over the age of 70, who are presumably
normal, have electrocardiograms indicative
of myocardial damage. These abnormal
electrocardiograms, however, are evidence
of arteriosclerotic myocardial disease, not
of aging.

The arteries and veins become elongated
and dilated from progressive deterioration
of their elastic tissue, and there is some
thickening of the intima. Simple intimal
thickening is evidently a physiological pro-
cess, for it begins in the first years of life
and occurs regularly in all but the smallest
muscular arteries. Thickening of the in-
tima after the fourth decade is due to in-
crease of collagenous tissue, and shows
fatty, hyaline and calcific changes as well.
It gives rise to the typical picture of ar-
teriosclerosis.

All the evidence indicates that arterios-
clerosis is not a simple wearing out of the
arterial coats that comes with age, but that
it is a disease ; a disease, it is true, that
manifests itself, mainly, but by no means
exclusively, during the period of senesc-
ence. It remains a challenge to scientific
investigation and a problem for construc-
tive therapy.

Changes in function of the heart and
arteries occur with advancing years. The
pulse rate remains fairly constant until
about age 65, when it tends to increase to
a slight degree. The cardiac output, meas-
ured under basal conditions, declines very
slightly in old age. This results largely
from the lessened oxygen consumption of
the body.

The idea that with increasing age there
is a progressive rise in blood pressure still
finds general acceptance. The term hyper-
tension is employed far too loosely. True
arterial hypertension, which so commonly
leads to cardiovascular disease, is charac-
terized by an elevation of both systolic and
diastolic pressures. Systolic hypertension,

without rise in diastolic pressure, has an
altogether different mechanism and is the
result, not the cause, of cardiovascular dis-
turbances. The common form of hyper-
tension met with in the aged is a systolic
hypertension. In the later decades of life
the systolic blood pressure may rise to about
140 or 160 mm. of mercury, while the dias-
tolic pressure remains unaltered. This
systolic hypertension and increase in pulse
pressure is not caused by narrowing of the
peripheral arterial bed and does not place
an added strain on the heart and arteries ;
it is the result of the loss of elasticity and
the increased atherosclerosis and rigidity of
the aorta and large arteries. The increas-
ing length and width of the aorta and large
arteries compensate for their loss of elas-
ticity and help to keep the internal tension
of the aortic wall constant. The increase
in systolic pressure in the aged is an ex-
pression of loss of arterial elasticity, and in
its effect on cardiovascular dynamics is a
beneficent reaction.

In their totality, these changes of the
organism lead to changes in function. When
he is at rest, or under no great physical
strain the bodily functions of the aged per-
son are normal. The temperature of the
body, the level of sugar and other chemical
constituents of the blood, the cardiac out-
put, the respiratory exchange, the kidney
function all compare favorably to similar
functions in youth. But as soon as the aging
body is exposed to unusual or greater strain,
we find that the range of response of the
various organs is curtailed, and that the
power of self-regulation of the body to
maintain a constant internal environment,
the function that Cannon calls homeostasis,
is lost. An aged person does not tolerate
excessive cold or heat, he cannot adapt him-
self to extreme environments. His heart
functions well when little demand is made
upon it, but it cannot respond to the load of
greater exertion. So it is with all of the
bodily functions. With age the bodily re-
serves are encroached on more and more
and gradually the physical limitations
placed on the body greatly limit its range
of response and its capabilities. Whereas

Boas — Phenomena of Aging

69

the young person can abuse his body, and
avertax his strength with little deleterious
results, such efforts in the aged soon lead
to disaster.

The process of repair of tissues after in-
jury is altered in the aging organism.

With progressing age there is a gradual
change in the natural resistance of the body
to infection. Pathologic changes in various
organs, that become increasingly frequent
with advancing years, bring about a les-
sened local or organ resistance to infection.
Thus pulmonary emphysema favors the de-
velopment of bronchitis and bronchopneu-
monia, prostatic enlargement, or large cys-
toceles allow of ready infection of the blad-
der, circulatory impairment in the extremi-
ties often leads to serious infection and
gangrene.

In treating aging persons, the physician
must give constant consideration to the loss
of youthful resilency and adaptability of
their tissues and organs, and to their pro-
gressively lessened range of response to
the calls made on them by the demands of
daily living. The young person can abuse
his body almost with impunity ; he can exer-
cise to complete fatigue, he can permit him-
self excesses in eating and drinking, he can
smoke too much, he can go without sleep.
His recuperative powers are great, and
rarely does he do himself permanent dam-
age. But when middle age is passed, the
body can no longer adapt itself so readily
to such extreme stresses; soon some struc-
ture or function gives way and leads to the
beginning of disease. Thus, with advanc-
ing years, the individual must learn his
gradually increasing limitations, and ar-
range his living so that he does not overtax
the weakening organism. Here again one
must try to strike the balance between the
maintenance of physical fitness, and ex-
cesses that lead to overstrain.

With advancing years, and the accom-
panying lowering in the basal metabolic
rate, and lessened physical activity the
caloric needs diminish. Absolute figures
cannot be set down for each age group, but
the principle is clear that with advancing
years and diminished activity the food in-

take must be cut down. Most persons past
age 70 who live very quiet lives should con-
sume between 1500 and 1800 calories. The
protein intake should be reduced in pro-
portion to the caloric intake. Thus a 1500
calorie diet should contain about 45 grams
of protein.

Experimental studies in nutrition have
demonstrated an intimate relationship be-
tween the qualitative composition of the
diet and health. They have shown that in-
adequate diets may cause disease, and that
the duration of life of individual animals,
and the health of successive generations
can be affected at will by alterations in
the diet. One must distinguish between a
minimum adequate diet and an optimum
diet.

The results of inadequate dietaries may
be very slowly cumulative and may not be-
come apparent for many years. Many of
the manifestations of aging and disease in
older persons, that today are accepted as
inevitable results of senescence, may well
be the result of life-long faulty dietaries.
The ordinary American diet is more defici-
ent in calcium than in any other element.
As a result adults experience steady long
continued loss of calcium through the years.
This does not become superficially mani-
fest because the great calcium stores in the
bones constantly make up for the calcium
losses in the blood and tissues. But as a
result of this constant depletion the bones
become poor in calcium and more fragile.
The osteoporosis of the aged may well be
a result of a dietary fault, and not an in-
evitable accompaniment of aging. An in-
take of almost one gram of calcium a day
is needed to maintain the calcium balance
of the body. The best sources of this
mineral are milk which contains about one
gram to the quart, cheese and green leafy
vegetables.

Snapper has pointed out that arterios-
clerosis occurs very rarely in northern
China, in spite of the fact that diabetes is
very common. He suggests that fundamen-
tal differences in dietaries may underly
this phenomenon. The Chinese diet con-
tains only small amounts of cholesterol but

70

Boas — Phenomena of Aging

considerable quantities of unsaturated
fatty acids, especially of linoleic and lino-
lenic acid. He states that the average
cholesterol content of the blood of Chinese
is lower than that of Westerners, and sug-
gests that this may account for the les-
sened incidence of lipoid infiltration of the
arterial wall among the Chinese.

As yet no knowledge exists of a specific
relationship between individual vitamins
and aging, but in the light of experimen-
tal work it is evident that the provision
of an adequate supply of vitamins through-
out life will help to maintain health, and
probably postpone some of the disabilities
that come with advancing years. Physi-
cians have learned to recognize some of
the more extreme manifestations of vita-
min deficiencies, and have become aware
that vitamin lack may cause disease un-
der unexpected circumstances. It is not at
all unreasonable to suppose that many of
the lesser disturbances that develop with the
years are ascribable to dietary deficiencies.
Some of the mental disturbances of the
aged are pellagra-like and can be cured by
the administration of nicotinic acid. Often
a primary disease, such as a heart disease
will interfere with the appetite and with
the absorption of food, so that secondary
symptoms due to dietary deficiencies be-
come manifest. In older persons, too, we
may encounter dietary fads and idiosyn-
cracies that lead to disease.

Cheilosis, the macerated lesion at the
angles of the mouth, has been repeatedly
described in recent years as pathognomonic
for riboflavin deficiency. Recently it has
been shown that this lesion in older per-
sons is often due to ill-fitting artificial den-
tures with too short a vertical dimension,
causing the upper lip to overhang the
lower. This allows the saliva to escape at
the angle of the mouth and creates a moist
pocket where fungi and bacteria grow on
the epithelial debris.

With age there is a slow decrement in all
of the functions and in the psychologic re-
actions of the body. There is impairment
of bodily strength, of swiftness and exact-
ness of motion. But there is great varia-

bility in the time of appearance of these
changes, and many a superior oldster may
in these functions excel the average-
younger individual. There is a general be-
lief that old persons have lost the faculty
of learning new disciplines and new proce-
dures, that they are resistant to new ideas.
Psychologic studies have thrown doubt on
this view and many believe that the edu-
catability of a person does not necessarily
decline with age. The liberalism or conser-
vatism of their outlook on life are deter-
minants as important as their chronologic
age. Certainly wisdom, a function involv-
ing experience and judgment is preserved
in age.

Impairment of memory is universally
accepted as a stigma of aging. Memory
is a function of attention. The physical
weakness of the aged, and the assumption
by society that they are no longer useful
leads to a sense of inadequacy, and to a
withdrawal of attention. Lack of memory
thus is often actually lack of attention.
Older people are more conservative than
the young; they resist changes in their
mode of life, they resist new ideas in man-
ners and morals. Again this is not neces-
sarily the result of senile changes in their
brains and modes of thought, but may re-
sult from the sense of inadequacy which
their insecure position in society impresses
on them, which gives the old person an emo-
tional need for an unchanged world. Many
of the mental and emotional changes mani-
fested in elderly persons are due less to
aging and regression of their mental facul-
ties, than to the kind of life forced on them
by a heedless society. Lawton has pointed
out that economic and social insecurity
play a large part in hastening mental de-
terioration in older persons. A man who
has worked most of his life, who has sup-
ported and brought up a family, who has
regarded himself, if he ever gave thought
to the matter, as a useful member of so-
ciety is suddenly without work and with-
out income for reasons of age alone. In
spite of his best efforts, current concepts
and customs make it impossible for him
to obtain employment and maintain his in-

Pizzolato — Blood Supply of Sternum

71

dependence. He becomes dependent on his
children or on society. He learns that he
has no further function in life, yet in-
stinctively he clings to life. Is it not to be
expected that this change in his status,
forced on him by the workings of the cul-
ture of the society within which he lives,
rather than by any cause residing within
himself, should color his mental and emo-
tional reactions? And since this same pat-
tern is repeated in multitudes of members
of our society, and since they react in
similar ways, the unwarranted conclusion
has been drawn that many of the mental
and emotional characteristics of the aged
are caused by intrinsic biologic changes, in-
stead of recognizing that they are the re-

THE BLOOD SUPPLY OF THE
STERNUM* *

I. X-RAY STUDIES OF INJECTED STER-
NUMS SHOWING VENOUS RETURN

PHILIP PIZZOLATO, M. D.f
New Orleans

Because of the recent interest in the es-
tablishment of the marrow cavities as a new
route for parenteral therapy and the use
of marrow for diagnosis, we have under-
taken to investigate the intricacies of the
blood supply of the sternum. Tocantins1
in 1940 demonstrated that blood, glucose
and saline solutions could be introduced into
the medullary cavities of man and rabbits
without difficulty. He also injected mer-
cury into the marrow cavity and recorded
the venous outflow by x-ray photographs.
Disadvantages in the use of mercury are
that it frequently becomes dislodged from
the injected site and is easily attacked by
acids used in the decalcification of bones.
Benda2 injected radio-opaque substances

fFrom the Division of Hematology, Department
of Pathology, Charity Hospital of Louisiana at
New Orleans, and the Department of Pathology
and Bacteriology of the Louisiana State University
School of Medicine, New Orleans, Louisiana.

*Presented before the American Federation of
Clinical Research 6n March 28, 1944, at Louisiana
State University School of Medicine, New Orleans,
Louisiana.

suit of external conditions imposed on
them by the cultural pattern of the society
within which they live. The validity of this
view is strengthened by the repeated ob-
servation of intellectual vigor, and emo-
tional balance in individuals who have
passed the eighth decade of life, and who
because of certain fortunate circumstances
are enabled to continue lives of financial
independence, and intellectual or creative
productivity.

I have discussed some of the impor-
tant phenomena of senescence and have
tried to distinguish them from disease in
old age. Such knowledge is basic to scien-
tific, clinical, and social study of our aging
population.

into the sternum of living patients but the
method was not entirely successful because
the medium escaped into the general circu-
lation before satisfactory roentgenograms
were obtained.

In our studies we used 5 per cent ferric
ferrocyanide and lead chromate as blue and
yellow pigments, in a 20 per cent vinylite
solution in acetone; the lead compound be-
ing more opaque to x-ray, whereas the blue
mixture is excellent for translucent prepa-
ration. In these photographs injections were
made in the manubrium and in various por-
tions of the body of the sternum, one to five
cubic centimeters of the mixture being in-
jected in each site. The medium flowed
with slight difficulty and soon entered the
sternal tributaries of the mammary vein.
The bones were x-rayed and then cleared
in oil of wintergreen. Figure 1 C shows
the sternum of a seven year old boy which
was injected in the middle of the body and
in the manubrium and then cleared. The
medium has entered the surrounding ven-
ules and the sternal tributaries of the mam-
mary veins. Figures 1 A and B show an
opaque material in the manubrium and in
various portions of the sternum, as well as
in the mammary vein. Finer details of the
venous outflow were noted in the cleared
preparations. We were unable to find any
sternums as pictured by Tocantins in which

72

Clinico -Pathologic Conference

large blood vessels ran through the body.
However, we did find in our observation of
the adult a few large branches anastomos-
ing at the lower portion of the sternum, and
in children, small branches connecting one
center of ossification with another.

CLINICO-PATHOLOGIC CONFERENCE
CHARITY HOSPITAL
CASE HISTORY

J. M., a colored male, aged 6 months, was ad-
mitted April 18, 1944 and died April 27, 1944.

C. C.: Jaundice, painful left side, fever.

P. I.: On April 17 (day before admission), the

mother first noted that her infant was jaundiced
and was passing white stools and dark urine. The
infant seemed feverish, but no temperature meas-
urement was made. There was apparent tender-
ness on the left side of the abdomen.

P. H.: Patient was born prematurely at Char-

ity Hospital on October 23, 1943, after an eight

REFERENCES

1. Tocantins, L. M. : Rapid absorption of substances*
injected into the bone marrow, I’roc. Soc. Exper. Biol. &
Med., 45 :292, 1940.

2. Benda, It.. Orinstein, E., and Depitre : Injections
intramedullaires osseuses de substances opaques chez
l’hpmme, Sang, 14:172, 1940.

month primiparous gestation. Birth weight was
4 pounds, 6 ounces. There were no abnormalities
of delivery or of neonatal period. Physical ex-
amination disclosed an inguinal hernia.

The mother was found to be syphilitic shortly be-
fore delivery; no antiluetic treatment had been
given. In spite of repeated clinical evaluation,
bone x-rays, and serologies, no evidence of syphilis
was found in the infant.

During the second week of life, the infant’s ab-
domen suddenly became distended, due to me-
chanical bowel obstruction resulting from a strang-
ulated inguinal hernia. At laparotomy a gangre-
nous section of small bowel incarcerated in the in-
guinal sac made it necessary to resect 6 cm. of

Clinico-Pathologic Coyiference

73

ileum and to perform a double-barreled ileostomy.
The infant survived a stormy postoperative
course, after which the spur was finally clamped,
and on the tenth postoperative day feces passed
through the anus. Three weeks after laparotomy,
the colostomy was closed. At five months of age,
the infant’s hernia was repaired, and he was dis-
charged on April 5, 1944, weighing 9 pounds.

No other abnormalities were noted at the time
of laparotomy, nor were there any episodes of
bleeding during the entire first period of hospitali-
zation. The usual neonatal jaundice was in no
way complicated or prolonged.

P. E. : T. 97.6° (R), P. 120, R. 62. Wt. 10y2

pounds, head circumference 37 cm., length 57 cm.
The infant appeared fairly well nourished but
fretful. Moderate postural deformities of the head
were present. There was evident icterus of skin
and sclerae. Examination of the chest disclosed
somewhat noisy respirations, slight retraction of
the thoracic soft parts, and occasional scattered
coarse rales. The abdomen was moderately dis-
tended, but there was no apparent bowel obstruc-
tion. Palpation of the left upper quadrant
elicited tenderness; the spleen was not palpable.
A non-tender liver could be felt 1 cm. below the
right costal margin. There was a well healed
right hernioplasty scar.

Laboratory: Hgb. 55 per cent (Sahli), RBC

4,200,000, WBC 12,500; differential: 39 per cent
neutrophils, 2 per cent immatures, 4 per cent
eosinophils, 1 per cent basophils, 5 per cent mono-
cytes, and 49 per cent lymphocytes. A sickling
preparation was negative. Corrected sedimenta-
tion rate was found to be 1 mm. Bleeding time
was 14 minutes, clotting time six minutes, and
prothrombin time failed to show a clot in 30 min-
utes. On April 24, after daily parenteral adminis-
tration of vitamin K, the bleeding time was 11
minutes, clotting time 4 minutes, and blood pro-
thrombin concentration 100 per cent of normal.

Three urinalyses showed traces of reducing sub-
stance. Bile was found in the first two specimens
but not in the last (on April 26). Qualitative
tests for urobilinogen were negative.

Bile could not be found in a clay-colored stool
on admission nor in a yellow sample on April 26,
but occult blood was present in the feces on this
date. Rectal swab culture for typhoid and dysen-
tery organisms was negative.

The serum proteins were 8.3 gm. per cent on ad-
mission, van den Bergh 13.1 units (direct).
Cephalin-cholesterol emulsion showed a 3 to 4 +
flocculation. Kline and Kolmer were negative on
two occasions during this admission. Mantoux
(0.1 mg.) was positive; Schick equivocal.

X-rays of the bones were within normal limits.

Course: Synthetic vitamin K (2 mg.) was

given intramuscularly twice daily up to death.
The infant was not transfused. His urine re-
mained consistently orange-yellow. On the day

after admission, his stools became yellow.

On April 21, the infant became restless, irritable,
and feverish, his evening temperature reaching
102.2°. The fever had subsided by the afternoon
of the next day; the infant again appeared to be
fairly well.

On April 26, streaks of bright blood were seen
in the stool; by that afternoon the stool was black,
giving a positive test for occult blood. By
evening the stools were again yellow.

On April 27, at 10:30 a. m., an unsuccessful at-
tempt was made to draw blood from the jugular
vein. The infant’s rectal temperature was then
98.6°. Immediately thereafter he was carried
from the ninth floor to Delgado Amphitheatre. On
his return to the ninth floor about noon he was
found to be cold, clammy, and cyanotic, with ir-
regular respirations. His temperature was now
95.8°. Oxygen inhalations were begun. By 2 p.
m., respiration had ceased. Resuscitation was un-
successful.

Dr. Hill : This colored male, six months
of age, developed jaundice, pale stools, dark
urine, and left abdominal tenderness just
the day before admission. This question-
able history is the only information avail-
able.

The mother had been found to be syphi-
litic shortly before the premature delivery
of this infant but had received no treatment
during this, her first pregnancy. We ex-
amined the infant repeatedly, and there
were never any physical, serologic, or
roentgenologic evidences of syphilis found.

During the second week of life, he was
transferred to the Surgical Department for
relief of a strangulated inguinal hernia ;
operative procedures will be described by
the surgical resident. The patient was dis-
charged at the age of five months, just
three weeks before returning for this sec-
ond admission. We understand that during
the various operations, there were no as-
sociated abnormalities noted, and there
were no apparent bleeding tendencies.

At the time of his second admission,
there was slight tenderness in the left upper
quadrant of the abdomen, but there was no
evidence of bowel obstruction and no true
muscle spasm. This tenderness disappeared
during the first day in the hospital. From
the history and physical findings alone, no
diagnosis could be established. Luetic hepa-

74

Clinico-Pathologic Conference

titis was most strongly considered, though
subsequent studies and clinical course
seemed to exclude this possibility.

The sedimentation rate was normal. In
spite of parenteral administration of vita-
min K, the bleeding time remained pro-
longed while the prothrombin and clotting
times returned to normal levels. Examina-
tion of the urine and stool suggested that
the jaundice was of the obstructive or re-
gurgitative type. Kline and Kolmer tests
were negative on two separate occasions
during this last admission. Aside from a
slight elevation of temperature on the
fourth hospital day, the child’s course was
afebrile, and he appeared quite well until
the final dramatic episode, to be discussed
later.

There was a small amount of gross blood
in the stool on the ninth day after admis-
sion, at which time the prothrombin and
clotting times were normal, though the
bleeding time was still prolonged.

Two hours before death a venepuncture
was done ; during the next hour he was
taken to a surgical conference for discus-
sion of the results of the earlier bowel re-
section. When returned to the ward, he
was in extremis, apparently in a state of
shock, cold, clammy, cyanotic, and with
marked respiratory difficulty. In spite of
efforts at resuscitation, he expired.

It seems obvious that the infant had some
sort of obstructive or regurgitative jaun-
dice. Most of the laboratory procedures
were not repeated for confirmation, so we
must accept the results of single examina-
tions. What are the possible causes of such
jaundice in an infant of this age?

Acute yellow atrophy should be ruled out
by the benign course until the day of death.
This condition produces prolonged bleed-
ing, clotting, and prothrombin times, but
the relatively benign course, meager gas-
trointestinal and cerebral symptoms, to-
gether with the response of prothrombin
to parenteral vitamin K all argue against
such a diagnosis. Furthermore, there
seemed to be no toxic or infectious basis
discoverable in the history.

Acute catarrhal jaundice is rare in in-
fants, and absence of even mild gastroin-
testinal symptoms in this condition would
be unusual. The prolonged bleeding time
does not fit very well. In view of the
hemorrhagic manifestations, Weil’s disease
or other types of infectious hepatitis should
be considered. These, however, usually have
marked constitutional symptoms, and this
child did not exhibit high fever, prostration,
myalgia, or conjunctival hyperemia.

Cirrhosis, though extremely rare at this
age, could be suspected from the presence
of hemorrhages, although the acute onset
and lack of evidences of portal hypertension
make it unlikely.

Regardless of the fact that we could dem-
onstrate no objective evidence of syphilis
in this particular infant, we still have to
consider luetic hepatitis, particularly on the
basis of the maternal status and our knowl-
edge that syphilitic hepatitis, although fre-
quent as a pathologic finding, often pro-
duces bizarre and atypical clinical mani-
festations. Jaundice is usually absent or
minimal in luetic hepatitis in infancy. Liver
abscess seems unlikely in view of the nor-
mal sedimentation rate and leukocyte count.
Poisons could be considered, but no sus-
picion is raised by the history and no toxi-
cologic examination was made.

Is it possible that adhesions following the
earlier operative procedures could obstruct
the common bile duct? Certainly this is
not an example of congenital atresia, since
the jaundice did not appear until the sixth
month, whereas in atresia it becomes in-
creasingly severe after the second or third
week. Enlargement of lymph nodes ad-
jacent to the common bile duct due to
syphilis, tuberculosis, or neoplasm should
be considered, and parasites have been
known to ascend and occlude the biliary
system. One feature which speaks strongly
against a purely obstructive jaundice is the
elevation of cephalin-cholesterol floccula-
tion test; a 2 to 4 plus reaction has been
found in no more than 5 per cent of such
cases and then is usually associated with
hepatic damage.

Cholecystitis and cholelithiasis are very

Clinico-Pathologic Conference

75

unusual in infancy, and hydatid cyst of
the liver also seems adequately excluded by
its rarity; primary carcinoma of the liver
in infants does not produce jaundice but
usually only asymmetric hepatic enlarge-
ment due to the tumor mass.

Independent of these considerations of
liver pathology, there are certainly many
other possibilities. There are two periods
in the child’s life when peptic ulcer is likely
to occur : in the newborn with sepsis and
during later childhood. It has also been
reported to occur in severe hepatitis. The
reasons for the occurrence of ulcers in these
situations is not clearly understood. Aside
from its rarity, peptic ulcer in childhood is
frequently asymptomatic and extremely
atypical in its manifestations. It usually
produces only gastrointestinal hemorrhage
or perforation. The total duration of life
following a rupture of such an ulcer is rare-
ly longer than 24 to 36 hours. Occasionally,
ulcers are found in association with con-
genital anomalies of the intestinal tract.
One such case was reported with severe
ulceration appearing in the stoma of a blind
ileal pouch ; this same thing might possibly
occur with a Meckel’s diverticulum.

Thrombocytopenic purpura should have
been considered, particularly when the pro-
longed bleeding time persisted after correc-
tion of the prothrombin deficiency. In this
condition, sudden hemorrhages, particu-
larly intracranial, can occur to explain such
a dramatic terminal episode as this baby
exhibited. Hemorrhage, however, would not
produce these evidences of obstructive
jaundice but rather would present features
suggesting hemolytic types. This infant was
not transfused as he should have been, had
thrombocytopenic purpura been considered.

After our last conference dealing with
miliary tuberculosis, we cannot afford to
overlook this infant’s positive Mantoux re-
action.

What relation did jugular puncture have
to the terminal episode? Is it possible that
the vein was entered and allowed to bleed
into the mediastinum? Is it possible that
sudden death was caused by a massive
pneumothorax, produced by tearing the

dome of the pleura? What happened in
the hour following this manipulation?

Summing up, the most likely possibility
is that this infant had an acute hepatitis
of unrecognized cause. It is entirely pos-
sible that the jaundice could have been due
to a benign process, such as acute catarrhal
jaundice, and therefore not a direct cause
of death. Ulceration of the intestinal tract
is extremely likely but so is mediastinal
hemorrhage and massive pneumothorax.

Dr. Platou : We have said repeatedly that
there is never any harm in “waiting for
proof” before instituting therapy in con-
genital syphilis, and this case illustrates
that point nicely. Consider what a problem
we would have had today if we had assumed
this infant to be congenitally syphilitic and
had administered three or four injections
of an arsenical drug ! As you know, there
were never any cutaneous, mucosal, sero-
logic, or x-ray evidences of syphilis in this
baby. I would be very surprised if the
pathologists are able to demonstrate any
lesion attributable to this disease. Some-
one might say that this could be an example
of congenital syphilis destined to present
the first objective manifestations later in
childhood ; even so, specific treatment could
not be justified during either of these pe-
riods of hospitalization.

What happened during the last hour of
life? Perhaps the student who told me
there were significant physical findings ap-
pearing during this time would be willing
to supplement the record in this regard. Is
that student present.

Student : When I examined the patient,
the abdomen was markedly distended ; I
could not palpate the organs. I did not take
the temperature. Respirations were about
50, pulse was over 150, and the child was
in bad shape.

Dr. Platou : I think the immediate cause
of death was a perforation, not pleural
or mediastinal, but intestinal. The jaun-
dice may have been contributory in some
way to a perforated peptic ulcer or there
may be an ulcer lower in the intesti-
nal tract, perhaps at the site of the previous
anastomosis. At any rate, the student’s

76

Clinico-Pa thologic Conference

finding of marked abdominal distention
may support our feeling that the terminal
episode was caused by a fulminating peri-
tonitis.

There is a valuable lesson to be learned
here; repeated injections of vitamin K
were given over a period of four days be-
cause of prolonged bleeding and clotting
times, with an inadequate prothrombin
level. We have pointed out time and again
that one should never rely on vitamin K
alone to control hemorrhagic manifesta-
tions. Vitamin K may correct one deficit in
the bleeding mechanism and one only.
There are, as you know, many other causes
of hemorrhage besides prothrombin defici-
ency. This infant should certainly have had
several small transfusions in addition to
the vitamin K which was given. A pro-
longation of bleeding time persisting after
correction of prothrombin level should have
made the indication for transfusion abso-
lute. We regret that no platelet count was
made, and the retraction of the clot was not
observed ; these determinations would have
been very helpful.

I should like to call on the representative
of the Surgical Division to give us some
information concerning the earlier opera-
tive procedures.

Dr. Joseph Morris : I can give you some
facts about the first hospital admission.
When he was 13 days old, he started vomit-
ing and we noticed that his abdomen was
distended. Twenty-four hours later, Dr.
Martin, our chief resident at the time, was
called to see him. There was a hard mass
in the right inguinal region. He was oper-
ated upon for a strangulated inguinal
hernia. A loop of ileum about 8 cm. long
was found in the hernial sac, and there
were two small perforations in this seg-
ment. It was hard to decide what to do
because enterostomy is known to be univer-
sally fatal in infants, but having nothing
else to do, we did that. On the third post-
operative day we clamped the spur with
hemostats, hoping to prevent death from
loss of fluid. Three days later, it was seen
that the gut containing the spur had pro-
lapsed after the hemostats were removed.

I further aggravated this by trying to see
how deep the spur was and separated the
two segments of bowel near the site of
enterostomy. We thought the child would
surely die then, but Dr. Martin put two
more hemostats on, and we fastened the
handles to a splint to prevent prolapse of
the gut. After three more days, these came
off ; the pressure dressing was applied to
divert the fecal stream into its normal
channels, and the patient started having
bowel movements. It was necessary to give
blood and fluids by vein.

Three weeks after operation, we tried
to close the enterostomy opening, but it
broke down later. A dressing was applied
to hold it in position, and it closed spon-
taneously. When the patient weighed nine
pounds at five months, his hernia was re-
paired, and the gut was entered again in-
advertently. It took about three hours to
repair the hernia.

The baby weighed only four pounds at
birth but was nine months gestation. His
hernia was repaired, and he had an un-
eventful recovery.

I do not know who did the venepuncture.
I did not notice that the abdomen was dis-
tended (as the student stated) but I did not
examine him. The jaundice was not as
marked as it had been on admission.

Dr. Dieter: Was there any history of
drug administration?

Dr. Stark : No. There is a lot of mystery
connected with this case, and I am afraid
some will remain after we show the organs.
Dr. Hill has diagnosed this case properly.
One point raised in the clinical history was
what happened during the last few hours
of this child’s life. After seeing the pathol-
ogy, it is still a mystery to me how he ap-
peared so wrell up to the time of death. At
autopsy we found that he had a peptic ulcer
which had ruptured and caused a diffuse
peritonitis. It is hard for me to imagine
that such a condition would have given rise
to symptoms only in the last hour of life.
It must have taken a day or more for this
peritonitis to develop. There was an episode
of sudden pain and restlessness and fever
about six days before death, but it is hardly

Clinico-Pathologic Conference

77

possible that the child could have lived all
these days with a ruptured ulcer. So we
have to put the time in the last twenty-four
hours. There were no marked adhesions in
the peritoneal cavity.

So much for the immediate cause of
death. As an incidental finding, there is a
diverticulum of the stomach near the car-
dia about 1 cm. in diameter. I doubt if such
a similar diverticulum in the duodenum was
the cause of rupture.

We can dispense with the rest of the or-
gans quickly. The heart, lungs, spleen, and
kidneys showed nothing remarkable. The
lungs showed a few hemorrhages and one
small infarct, a few areas of bronchopneu-
monia, but I do not attribute more than
secondary importance to them. As far as
the jugular puncture is concerned, there
was nothing suspicious in the neck to indi-
cate hemorrhage or pneumothorax. The or-
gans of the neck were dissected and showed
no obstruction to the respiratory tract. We
can explain death adequately on other
grounds.

The specimens from the operative site
should be of great interest to you. The
cecum and ascending colon and the pouch
formed by the anastomosis between two
loops of the ileum were found to be normal ;
there were some adhesions surrounding
this area. As far as we can tell, the opera-
tion was a complete success in reestablish-
ing continuity of the bowel.

Now we come to the biliary tract. The
conclusion was drawn that either obstruc-
tion to the biliary outflow had been present,
or massive liver damage had occurred. We
can safely say there was no obstruction to
the bile duct, because at autopsy we could
squeeze bile from the bile duct into the
duodenum without difficulty. As far as in-
trahepatic obstruction is concerned, it is a
little more difficult to demonstrate. How-
ever, we found no dilatation of the large
intrahepatic bile ducts which would be ex-
pected in obstruction of longer standing.

The gross specimen shows the liver to be
apparently of normal size and outline.
There are two cKanges, however : the green-
ish color of the liver, leaving only parts

of the right lobe a brownish-red, and the
slight hardening of the liver, and the fine
granulation of the surface (resembling
Morocco leather). This picture on gross
examination resembles that found in biliary
cirrhosis. However, on microscopic exami-
nation, we found that biliary cirrhosis
would not cover the entire pathologic pic-
ture, and if we had put this in a definite
category, I would classify it as subacute
necrosis or hepatitis. As for the cause, I
do not know what it is.

Some of the causes of liver necrosis are
known. I am happy that this child did not
have arsenicals because it would have made
our problem even more difficult. We can
at least rule this out. We also know that
this patient did not have poisoning from
chloroform, phosphorous, and other “liver
poisons.”

We think the nutritional element may
enter into the explanation. From recent
experimental work on nutritional factors, it
is reported that protein deficiency can pro-
duce liver necrosis, which is associated with
cirrhotic changes in those cases which re-
cover. This is of course experimental, so
we cannot draw any definite conclusions.
However, an infant who underwent a major
operation probably had a nutritional de-
ficiency as a result of the prolonged illness.

Another consideration is the possible
toxic absorption from the scrotal abscess.
We do know that bacterial toxins can pro-
duce liver damage.

SLIDES

Although the underlying pathology is
massive, widespread liver necrosis of a sub-
acute nature, the cause of death was peri-
tonitis due to rupture of the peptic ulcer.
One thought I can leave with you is that
there may be some connection between the
two since from experimental studies, tying
off of the bile duct of dogs causes bile re-
tention followed in a high percentage by
duodenal ulcers. The greatest number of
these dogs die of ruptured ulcer. One series
of clinical cases has been reported in which
there was a relationship between biliary ob-
struction and formation of duodenal ulcers.

78

Clinico-Pathologic Conference

Dr. Hill : A diagnosis of duodenal ulcer
in childhood is difficult because it is based
largely on suspicion instead of knowledge.
In older children there is symptomatology
similar to that in adults, but not in younger
age groups. Most cases in young children
begin with severe hemorrhage, and perfora-
tion, and the prognosis is bad ; they usually
die in 24 to 36 hours. Since no one can
prove me wrong, I am willing to guess that
this child, in the absence of the ulcer, might
have lived longer because of the response
of the prothrombin time to vitamin K. The
advantage of the cephalin-cholesterol test
is evident in differentiating obstructive
from regurgitative jaundice. The feeding,
I believe, was quite satisfactory, since he
was on the regular diet provided for pre-
matures, and did well.

Dr. Platou : There are two questions I
should like to ask. Was there any demon-
strable lesion of primary tuberculosis to
explain the positive Mantoux, and was

there any ulceration in the lower intestinal
tract to explain the blood-streaked stool?

Dr. Stark: The answer to both questions
is “no.” There was no evidence of tubercu-
losis in the lungs or tracheobronchial lymph
nodes, but lesions, if present, might have
been so small that careful serial sectioning
of the lungs would be required to exclude
their presence.

Dr. Hill’s Diagnosis:

(1) Prematurity.

(2) Incarcerated inguinal hernia (post-
operative) .

(3) Postoperative scrotal abscess.

(4) Hepatitis, etiology unknown.

(5) Peptic ulcer with perforation and
general peritonitis.

Anatomic Diagnosis:

(1) Peptic ulcer, duodenal, with per-
foration.

(2) Generalized peritonitis.

(3) Toxic necrosis of liver (subacute
yellow atrophy).

Editorials

79

NEW ORLEANS

Medical and Surgical Journal

Established. 18 UU

Published by the Louisiana State Medical Society
under the jurisdiction of the following named
Journal Committee:

Val H. Fuchs, M. D., Ex officio
For two years: G. C. Anderson, M. D., Chairman
Leon J. Menville, M. D.

For one year: J. K. Howies, M. D., Vice-Chairman
For three years: C. Grenes Cole, M. D., Secretary
E. L. Leckert, M. D.

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1130 Tulane Avenue, New Orleans, La.

The Journal does not hold itself responsible for
statements made by any contributor.

MEDICINE AND THE GOVERNMENT

As could be anticipated the profound eco-
nomic and sociologic changes that are tak-
ing place as result of the war have and will
affect the medical profession in the future.
At the present time there have been passed
several important bills which have a direct
bearing on medical practice. Just recently
the Service Men’s Readjustment Act, col-
loquially spoken of as the GI Bill of Rights,
was passed by Congress. This particular
Act will add materially to the cost of Gov-
ernment but even this eventuality should
not be considered with dismay by the aver-

age taxpayer. After all the men who have
gone into the armed forces have done so
at a very considerable sacrifice, a sacrifice
which might entail the loss of life or per-
manent injury, not to mention the disrup-
tion of the civilian status of the individual.
Physicians, because of the great need of
doctors, have entered the Army and the
Navy in numbers greater than any other
profession or business. Forty per cent of
doctors of this country are now engaged in
war work. Under the provisions of the GI
Bill of Rights these doctors will be given
the opportunity of taking additional train-
ing and additional courses which might be
spoken of as refresher or re-training
courses. The Government will not only give
these special courses but is prepared to fi-
nance extensive training of the young man
under 25 years of age whose education was
impeded or delayed, interrupted or inter-
ferred with as a result of the war. Re-
fresher courses are for only one year. The
latter training is for a period permitting a
man to complete his education in college or
professional school. The time permitted
has a direct bearing on the length of serv-
ice of the veteran. In addition to paying
the ordinary expenses of training, a small
allowance will be given for subsistence, and
books and other equipment necessary for
training will also be paid for.

One good feature of the Service Men’s
Readjustment Act has to do with financing
the young doctor who is just starting out
in the practice of medicine or as a matter
of fact to a limited extent any physician.
The amount of money loaned to each phy-
sician will not be great, a maximum of
$2000 which may be enough to tide over
the returning medical man until he gets
on his financial feet. Of course special pro-
visions are made for a man who has been
wounded or has a disability which is serv-
ice connected.

Another bill which has very definite im-
plications in the future of medicine is the
Public Health Service Act. One of the im-
portant provisions in this is to increase
the grants-in-aid made to the states under
title VI of the Social Security Act. Part

80

Editorials

of these funds are to be spent upon pre-
vention of and controlling the spread of
tuberculosis. It is recognized that tuber-
culosis is an extremely difficult disease to
control without a central authority. States
such as Louisiana which have an excellent
State Board of Health, have already pro-
vided for a tuberculosis division in their
state set-up. The effectiveness of these di-
visions in different states vary very mater-
ially, some are good, some are bad and
some are non-existent. It is to assist the
states in establishing and maintaining con-
trol measures of this disease that this
United States Public Health Service will be
a real aid, particularly to the backward
states and those that are financially unable
to do much about the problems of tuber-
culosis.

Tuberculosis has been for many years
now a quasi-public health disease. The cam-
paign against tuberculosis has been fought
by both lay and organized medical activities.
There is no doubt but that they have done
a fine piece of work, part of it from the
enthusiasm and willingness of certain
groups to assist the physicians in their ef-
forts to control the disease. It is to be
wondered whether or not the enthusiasm
and the interest of these groups will not be
lost when monies are to be provided by
taxation for the purpose of controlling the
spread of tuberculosis. What has been ac-
complished in the last three decades is re-
markable. Whether through the instru-
mentality of the Government greater gains
will be made remains to be proved.

There can be no doubt but that every
physician will approve of the GI Bill of
Rights. Some will approve and many will
disapprove of the further extension of Gov-
ernmental services, putting another finger
in the medical pie, but to a man the medical
profession will continue to protest the in-
corporation of the Children’s Bureau in the
Department of Labor, with its bureaucracy,
false sentimentality and lack of concern
about the individual physician. A long bow
was drawn when medical care of children
was placed in the Department of Labor. If
we are to have modified and magnified

bureaucratic medicine, why not put all med-
ical activities in the hands of the Public
Health Service, or better still why not have,
as the House of Delegates of the American
Medical Association has repeatedly peti-
tioned Congress, a Department of Health in
which the various health activities would
be taken out of this or that department and
put into the department that has no rela-
tionship whatever to anything except med-
icine? As the Government is now set-up
half a dozen different departments come in
contact with one doctor and his activities.
They should be amalgamated and put under
the direct supervision of a physician.
o

OUR MEDICAL DEBT TO FRANCE

Under this heading Dr. Guy Hinsdale*
points out that the physicians of America
owe much to French scientists and doctors
who have lived in the last five hundred
years. The names of many of these great
French scientists and physicians are known
to all doctors : Pasteur, Laennec and Claude
Bernard are outstanding examples but there
are others whose names are less familiar
but who have done much for medicine, both
by their writings, and by their teachings
to students of the United States who have
studied and worked under them.

Ambroise Pare, Desault, Corvisart and
Dupuytren were some of the earliest of
French physicians who enriched medical
knowledge. Larry invented the mobile mil-
itary hospital. Pinel introduced kind and
gentle treatment of the insane in place of
the barbaric methods that had been em-
ployed previously. Andral was an out-
standing pathologist and Baudelocque in-
vented the pelvimeter and improved the ob-
stetrics forceps. Mme. Boivin stressed the
dangers of forceps causing puerperal fever.
Louis was a great internist whose “Re-
searches on Typhoid Fever” brought to him
as students many Americans who subse-
quently became distinguished in the field
of medicine.

Trousseau and Dieulafoy were both great
teachers, the latter the author of a textbook

* Hinsdale, Guy: Our medical debt to France,
Ann. Med. Hist., 14:154, 1942.

Editorials

81

which went through fifteen editions and
was translated into English. Laveran, who
died only a few years ago, discovered the
parasites of malaria and for which research
he received the Nobel prize in 1902. Widal
is so well known as the discoverer of the
agglutination reaction that occurs in ty-
phoid fever that his name needs no intro-
duction. Charcot was one of the greatest
neurologists of any time. Broca’s name is
known to every one who studies the anat-
omy of the brain.

Magendi and Claude Bernard can be
listed among the great physiologists of the
past whose scientific contributions have
helped to make medicine what it is today.
Brown-Sequard was a conspicuous neuro-
physiologist.

In the field of tuberculosis, Laennec was
followed by outstanding students of this
disease, Davaine, Villemin, and Calmette,
amongst others. -To the Curies the patient
with carcinoma cured by radium owes ever-
lasting gratitude.

Eponyms indicating the importance of
the observations and studies of these dis-
tinguished Frenchmen are in daily use:
Meniere’s disease, Raynaud’s disease, Duch-
enne’s paralysis, Charcot’s joint, Landry’s
paralysis, Huchard’s disease, Dejerine’s dis-
ease, the Widal reaction are but a few ex-
amples of matters medical with which the
names of great Frenchmen will probably
always be connected.

o

BAGASSOSIS

The occurrence of a disease which is char-
acterized by pulmonary symptoms and
which is to be found only in those working
in the dust of the bagasse that is left over
after the extraction of sugar from sugar
cane, should be of particular interest to
Louisiana physicians, as most of the sugar
cane produced in this country is a product
of this state.

The disease was originally described by
Jamison and Hopkins. Recently eleven ad-
ditional cases have been presented by Sode-
man and Pullen.* These cases, as well as
those of Jamison, were observed in the

*Sodeman, W. A. and Pullen, R. L.

Charity Hospital of New Orleans. In the
present report of Sodeman and Pullen it is
pointed out that the clinical features of the
disease are such that it becomes a relatively
simple matter to recognize the condition.
Of prime importance are cough and dys-
pnea in the early stage of the disease.
Shortness of breath is present in all of the
cases and appears suddenly out of a clear
sky. The cough likewise occurs in all in-
stances. The sputum was bloody in four
of eleven cases. Usually it is scant and
mucoid. Retrosternal pain is often an ac-
companiment of the dyspnea and cough.
The fever is intermittent in character and
lasts from three to four weeks in most in-
stances. The respiratory rate is accelerated
but tachycardia is not a prominent symp-
tom. Physical examination of the chest ex-
hibits nothing of importance. Rales are
heard locally or diffusely scattered through-
out the lungs but this is by no means inva-
riable. As a matter of fact the physical
examination of the chest, as in viral pneu-
monias, shows a surprising paucity of phy-
sical signs as contrasted with the very
marked roentgenologic findings when the
lungs are x-rayed. There may be observed
a miliary mottling throughout both lungs
which is most pronounced in the hilar re-
gion.

The laboratory examinations are charac-
terized for the most part by the lack of
information that may be obtained by these
studies. The leukocyte count is variable,
averaging about 13,000 but it may vary
from 7-20,000. There is an increase in the
eosinophils but this increase may be ex-
plained on bases other than the type of in-
fection. There is practically no anemia. It
is interesting that in one of the cases there
developed a well marked polycythemia some
weeks after the acute phase of the disease
had terminated. Sputum examinations,
blood cultures, agglutination reactions and
tuberculin reactions are all negative. The
average stay in the hospital is 38 days.
The abnormal roentgenologic lung findings
disappear as the symptoms subside.

As to the pathogenesis of the disease,
there have been various theories advanced.

82

Organization Section

Jamison and Hopkins believe that it is due
to a fungus but this finding has not been
confirmed. Allergy has been incriminated
but Sodeman and Pullen made studies by
means of skin testing and do not believe
that allergy has anything to do with the
disease. It has been suggested that silicosis
of an unusual form might be the funda-
mental cause, as bagasse contains from 5-7
per cent silicum. However, the disease does
not in any way, form or manner resemble
silicosis. Sodeman and Pullen believe that
particles of bagasse enter the alveolar re-
gions and produce an irritative pathologic
reaction which is responsible for th° dis-
ease. They confirm this observation in the
study of two patients, in the first of whom
lung puncture was performed and in whose
pulmonary tissue were found “spicules” of
an irregular foreign material, microscopi-
cally similar to bagasse. These spicules also

rotate polarized light as does bagasse. In
the patient who came to autopsy similar
spicules were also found in the section of
the lung. Photomicrographs illustrating
this article show these spicules most beau-
tifully. The authors believe that the in-
flammatory reaction is initiated by particles
of bagasse which enter the lung and pro-
duce a reaction which tends to heal as re-
sult of the cellular response initiated by
these foreign particles.

Sodeman and Pullen prefer to call this
disease bagasse disease of the lung, inas-
much as the term bagassosis is a hybrid
word. The root of the word bagass is the
Anglo Saxon “baeg” according to Dr. Thad-
deus St. Martin, but the suffix “osis” should
be added only to words formed from Greek
roots. Perhaps it might be a satisfactory
solution of the difficulty to make use of an
eponym and to call the disease Jamison’s
disease after the man who first described it.

ORGANIZATION SECTION

The Executive Committee dedicates this page to the members of the Louisiana
State Medical Society, feeling that a proper discussion of salient issues will contri-
bute to the understanding and fortification of our Society.

An informed profession should be a wise one.

ACCOMPLISHMENTS OF OUR
LEGISLATIVE COMMITTEE

During the recent sixty-day session of
our state legislature a joint Committee on
Public Policy and Legislation of the State
Society and the Orleans Parish Society was
extremely busy in Baton Rouge looking
after the interest of organized medicine in
this state. This necessitated a close liaison
with the workings of the committees, the
status of important bills in which we were
interested, appearance before committees
and many other activities successfully to
conclude medical bills. I feel certain that
the average member of our profession does
not realize the great importance of this
committee. It commands the respect and
esteem of not only the doctors in the House
and Senate but of most of the members as
well as the executive officers of the state.
Unquestionably this status has been built

up over years of faithful and loyal service
to everyone concerned.

The committee reviewed 66 bills, collec-
tively, however it is not exaggerating to
state that many individuals of the commit-
tee reviewed an additional number of bills
which will bring the total to around 150.
It was found that 53 of these bills in one
way or another affected the practice of
medicine. After final analysis it was found
by the committee that 11 bills merited their
support. Twenty were opposed by the com-
mittee and they remained neutral on 22.

SUMMARY OF BILLS CONSIDERED

Reviewed by committee 66

Affecting practice of medicine 53

Supported by committee 11

Opposed by committee . . . 20

Not acted upon by committee 22

All of the bills supported passed and were
signed by the governor except a bill spon-

Organization Section

83

sored by the school board, known as House
Bill 689, which provided for the employ-
ment of swimming instructors, dentists,
medical doctors and so forth.

It is very interesting to note that the
bills which were opposed by our legislative
committee failed to pass; either killed in
committee, on the floor of the House or
Senate, or vetoed by the governor.

BILES OF SiPECIAL INTEREST

The Mental Health Bill, H. 405, after be-
ing amended, represented the wishes of the
State Society as recently expressed in the
House of Delegates, through the Committee
on Mental Health, and was passed.

Senate Bill 370, known as the Lunacy
Commission Bill, which provides for the
reorganization, selection and modus oper-
andi in the consideration of state commis-
sions appointed by judges and provides for
compensation, was passed.

Senate Bill 363, creating a board of an-
atomy to regulate the distribution of un-
claimed bodies, was amended by our legis-
lative committee to meet the wishes of the
Executive Committee and was passed and
signed by the governor.

The attempt made to establish a charity
hospital in Algiers, through House Bill 362,
was approved by the House but was vetoed
by the governor due to lack of funds.

The nurses’ bill, known as House Bill 137,
permitting the State Board of Nursing Ex-
aminers to issue temporary permits during
the present emergency, was passed and
signed.

It is very gratifying also to report that
House Bill 722, known as the Revenue Bill,
which exempted from occupational tax phy-
sicians registered in this state, was passed.

There were two bills introduced for the
training of crippled children. One, House
Bill 865, sponsored by the Cripple Chil-
dren’s Department of the State Department
of Health, for palsied children, which cre-
ated a training center in the Deaf and
Dumb Institute in Baton Rouge, after suc-
cessfully passing1 the House and Senate was
vetoed by the governor owing to an error
in appropriation. The other, House Bill

540, sponsored by the Louisiana Society for
Crippled Children, proposed a plan for the
training of crippled children in the various
schools of the state, using the present set-
up of our state educational system in the
teaching and handling of crippled children
in our public schools. This was passed and
signed by the governor.

Referring to the bills which were opposed
by the committee it is interesting to note
that one bill, known as House Bill 329, was
withdrawn. It provided for the discontin-
uance of future establishment of any insur-
ance companies in this state and would have
prevented, if desired, the formulation of
any legislation in the future for prepay-
ment medical insurance by the State So-
ciety.

There were a great many bills introduced
which would lower the standards and quali-
fications of pharmacists. The committee
was very fortunate in having all of these
bills killed or removed from the calendar.

The hardest fight which was encountered
was around Senate Bill 347 which per-
mitted the optometrists of this state to ex-
pand, making new provisions for their
board and permitting them to take care of t
eyes. With the timely effort of the Chair-
man of the Health and Quarantine Commit-
tee of the House, we were able, against as-
tute lobbyists, to defeat the measure. This
is not the first time we have had to compete
with new optometrist legislation and from
all indications this will be a source of fu-
ture irritation.

In passing you might wish to know that
the following bills which were introduced
were acted upon as follows: Qualifications
for dean of L.S.U. ; premedical require-
ments; status of interns at Charity Hos-
pital in New Orleans. The first two bills,
House Bill 459 and House Bill 461, were
withdrawn. The other, House Bill 460, pro-
vided that graduates of Tulane and L.S.U.
be entitled to internship in New Orleans
Charity Hospital. After being amended,
by use of the word “should” instead of
“shall,” this bill was passed by the House
and Senate. Report of final disposition has
not yet been received.

84

Organization Section

OBSERVATIONS

It is very distressing to continue to ob-
serve that some of our medical groups and
individuals give their support to lay organi-
zations in the planning, writing and hear-
ing of medical bills of which our legislative
committee has no knowledge. Surely they
should know that our legislative committee
is at all times ready to lend its effort and
wisdom in the production of sound, con-
structive legislation. Why do our doctors
fail to make use of this agency, giving pref-
erence and comfort to lay groups which in
the past they well know manifested little
interest in the ideas of the medical profes-
sion of this state? Some of the disagree-
ment and objectionable arguments before
the committees of the House and Senate
surely would be dispensed with ; these, as
you know, do not reflect any great credit
on either contending force.

When specialists are brought into consul-
tation concerning provisions of a bill af-
fecting their practice, they should give
more study and closely scrutinize the word-
ing of the bill, before pronouncing to the
committee their approval or disapproval of
same.

These are just a few of the more impor-
tant observations as a result of our recent
experience, offered in a purely constructive
manner. The logic is plain ; you can thus
obviate conflict, mis-statements, and what
is very important, assist your legislative
committee in assessing the merits of a pro-
posed bill for the benefit of the public and
physicians.

The friendly cooperation of the State
Society and Orleans Parish Society com-
mittees, the individual attention and team
work, have provided these good results.
Truly it can be said, without contradiction,
that the entire membership of our organi-
zation should be most grateful to these legis-

lative committees. Never have there been
more devoted and sincere workers for the
cause of organized medicine. The results
accomplished represent a stupendous job.
It is hoped that the reaction of our mem-
bers will be one of appreciation and grati-
tude. We will all enjoy the fruits of their
work as members of the State Society and
we should continue to give this committee
our hearty support.

Our members should be informed that
the Executive Committee of the State So-
ciety has taken very positive action against
the recent policy of the army and selective
service in preventing the enrollment of suf-
ficient number of qualified medical students
which will inevitably result in a shortage
of qualified physicians in the near future.
This would be of eminent danger to the
health and well being of our citizens. The
committee heartily agreed that the Miller
Bill recently introduced in Congress (H.R.
5128) should be supported to correct these
restrictions. Appropriate letters were ad-
dressed to chairmen of various committees
which have the bill under consideration.
All members of the State Society are asked
to read the editorial appearing in the Jour-
nal of the A.M.A. on July 8 (page 708).
Letters should be written to the various
congressmen indicated in this editorial and
also to our representatives and senators in
Washington protesting a non-American re-
striction of doctors and asking support of
the Miller Bill for correction of same.

We have received information that the
United States Public Health Service has
discontinued its attempt to relocate physi-
cians in supposedly critical areas. This is
due to the fact that so few applications
were received for physicians from these
areas and also physicians were not avail-
able for these relocations.

85

Louisiana State Medical Society News

LOUISIANA STATE MEDICAL SOCIETY NEWS

CALENDAR

PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS

Society

East Baton Rouge

Morehouse

Orleans

Ouachita

Rapides

Sabine

Second District

Shreveport

Vernon

Date

Second Wednesday of every month
Second Tuesday of every month
Second Monday of every month
First Thursday of every month
First Monday of every month
First Wednesday of every month
Third Thursday of every month
First Tuesday of every month
First Thursday of every month

Place

Baton Rouge
Bastrop
New Orleans
Monroe
Alexandria

Shreveport

LOUISIANA ASSOCIATION OF
PATHOLOGISTS

Dr. John R. Schenken, Professor and Head of
the Department of Pathology and Bacteriology of
the Louisiana State University School of Medicine,
was elected President of the Louisiana Association
of Pathologists at a meeting held on July 6, 1944,
at Charity Hospital. Dr. Bjarne Pearson, of Tu-
lane University, was elected Vice-Pi-esident and
Dr. E. S. Moss, of Charity Hospital, was elected
Secretary-Treasurer. Capt. John G. Arnold, of
LaGarde Hospital, addressed the Society on the
problem of malaria in the battle area.

o

APPROACHING MEETINGS
Southern Medical Association Meeting
St. Louis, November 13-16
It was the expressed judgment of the Council at
the annual meeting last November that Southern
Medical Association meetings are essential, as es-
sential in war times as in peace, if not more so —
that physicians, civilian and military, need medi-
cal meetings. There are many reasons why the
Council believes our annual meetings are essential.
The Council was agreed that a meeting should be
held this year unless conditions not then antici-
pated seemed to indicate a meeting should not be
held. However, it charged its Executive Commit-
tee with the responsibility of a final decision for
a meeting this year and the selection of the place
of meeting. The Executive Committee met in St.
Louis on April 4 and decided that there should be
a meeting and accepted the invitation of the St.
Louis Medical Society to meet in St. Louis.

The American Congress of Physical Therapy
will hold its twenty-third annual scientific and
clinical session September 6, 7, 8 and 9, 1944, in-
clusive, at the Hotel Statler, Cleveland, Ohio. Re-
habilitation is in the spotlite today — Physical
Therapy plays an important part in this work.
The annual instruction course will be held from
8:00 to 10:30 a. m,., and from 1:00 to 2:00 p. m.
during the days of September 6, 7 and 8. The
scientific and clinical sessions will be given on the

remaining portions of these days and evenings.
All of these sessions will be open to the members
of the regular medical profession and their quali-
fied aids. For information concerning the instruc-
tion course and program of the convention proper,
address the American Congress of Physical The-
rapy, 30 North Michigan Avenue, Chicago, 2, Illi-
nois.

The program for the Annual Meeting of the
Association of Military Surgeons of the United
States to be held at the Pennsylvania Hotel, New
York City, November 2-4 inclusive, is being rapidly
completed. In addition to addresses by the Sur-
geons General of the Army, Navy, and U. S. Pub-
lic Health Service and by other distinguished
guests, there will be formal papers, panel discus-
sions and scientific and technical exhibits on the
latest advances in military medicine.

The Ninth Annual Assembly of the International
College of Surgeons will be held on October 3, 4,
5, 1944, at the Benjamin Franklin Hotel in Phila-
delphia, Pa. The program will be devoted to War,
Rehabilitation and Civilian Surgery.

o

ALVARENGA PRIZE

The College of Physicians of Philadelphia award-
ed the Alvarenga Prize on July 14, 1944, to Dr.
Gervase J. Connor, Department of Surgery, Yale
University School of Medicine, New Haven, Con-
necticut, for an outstanding study entitled “An-
terior Cerebellar Function, An Analytical Study in
Functional Localization in the Cerebellum in Dog
and Monkey”.

The Alvarenga Prize was established by the will
of Pedro Francisco daCosta Alvarenga of Lisbon,
Portugal, an Associate Fellow of the College of
Physicians, “to be awarded annually by the Col-
lege of Physicians on each anniversary of the death
of the testator, July 14, 1883, to the author of
the best memorial upon any branch of medicine
which may be deemed worthy of prize”.

The College usually makes this award for out-
standing published work and invites the recipient

86

Louisiana State Medical Society News

to deliver an Alvarenga Lecture before the Col-
lege. The College may occasionally, as in this in-
stance, award the prize for an exceptionally im-
portant manuscript submitted in competition.

In 1940 this prize was won by Dr. Ernest W.
Goodpasture of Nashville, by Dr. Ernest Carroll
Faust, of New Orleans, in 1943.

o

MEDICO-LEGAL COURSES
The Harvard Medical School with the co-opera-
tion of the Medical Schools of Boston University
and Tufts College has planned a condensed one-
day conference and a one-week seminar in forensic
medicine. The one-day conference is to be held
October 4; the one-week course October 2-7. This
latter course is planned principally for medical ex-
aminers and coroner physicians.

For further information address Harvard Medi-
cal School, Courses for Graduates, 25 Shattuck
Street, Boston 15, Massachusetts.

o

PHYSICIAN-ARTISTS’ PRIZE CONTEST
The American Physicians Art Association, with
the co-operation of Mead Johnson & Company, is
offering an important series of War Bonds as
prizes to physicians in the armed services and also
physicians in civilian practice for their best ar-
tistic works depicting the medical profession’s
“skill and courage and devotion beyond the call of
duty”.

Announcement of further details will be made
soon by the Association’s Secretary, Dr. F. H.
Redewill, Flood Building, San Francisco, Cal.

o

INFECTIOUS DISEASES IN LOUISIANA
The Louisiana State Board of Health reported
that during the week ending June 10 there were
reported the following diseases in numbers greater
than 10: pulmonary tuberculosis 56, malaria 33,
measles 21, mumps 20, unclassified pneumonia and
typhus fever 12 each. During this week there were
reported also seven cases of poliomyelitis, of
which were reported three from Orleans Parish,
two from Terrebonne, one from East Baton Rouge
and one from Jefferson. For the week ending
June 17 there were listed 80 cases of malaria, 48
of measles, 35 of pulmonary tuberculosis, 30 of
bacillary dysentery, 19 of mumps, 15 each of hook-
worm infestation and septic sore throat. There
were five cases of poliomyelitis reported; Iberia
Parish with two cases, being the only parish with
more than one. There was 26 malaria cases re-
ported from military sources: 43 of these cases
reported in Jackson Parish. For the week ending
June 24 measles led all other reportable diseases
with 42 cases followed by 30 of pulmonary tuber-
culosis, 28 of mumps, 17 of unclassified pneumonia

and 14 of malaria. The seven cases of polio-
myelitis recorded this week came from around New
Orleans; five from Orleans Parish and two from
Jefferson. The weekly report which came out on
July 1 listed the number of venereal disease cases
for the previous four weeks. In this time 1329
cases of syphilis were listed, 1292 of gonorrhea,
42 of chancroid, 13 of granuloma inguinale and 12
of lymphopathia venereum. The non-venereal dis-
eases included the marked number of 74 cases of
pneumococcic pneumonia, 21 of malaria, 20 of pul-
monary tuberculosis and 14 of mumps. There was
a surprisingly large number of unclassified pneu-
monia cases listed, 320 in all, about fifty per cent
of the total for the entire year. The four polio-
myelitis cases that were reported came from dif-
ferent parishes throughout the state.

o

HEALTH OF NEW ORLEANS

The Bureau of the Census, Department of Com-
merce, reported that for the week which ended
June 17 there were 139 deaths in the City of
New Orleans as contrasted with 153 the previous
week. Of these patients who died 82 were white,
57 colored and 14 of the total were infants under
one year of age. In the week ending June 24 there
was a marked increase in number of deaths, there
being 164 deaths as contrasted with the three-year
average for the corresponding week of 146. Ninety-
four of the people of New Orleans who died this
week were white, 70 of them were colored and 15
of them were children under one year of age. For
the week which terminated July 1 there again was
a very marked increase in the number of deaths
in the city, there being 191 divided 128 white, 63
colored and 16 infants. The number of deaths in
the city this week was in numbers 48 greater than
in the corresponding week for the previous three
years. For the week ending July 8 there was a
sharp reduction in the number of deaths in the
city although this was still well above the three-
year average. One hundred and thirty-nine citi-
zens of the city expired, the white population fall-
ing to the amazingly low figure of 55 but the col-
ored quite high with 84 deaths. There were only
12 deaths in children under one year of age.

DR. JAMES ALEXANDER WHITE
(1868 - 1944)

The many friends of one of the best known ot
the older practitioners of the state, Dr. James
Alexander White, were dismayed to hear of his
death. For many years Dr. White was active in
medical circles in the State of Louisiana. He was
graduated from the College of Physicians and Sur-
geons in 1892.

Book Reviews

87

BOOK REVIEWS

Aesculapius in Latin America: By Aristides A.

Moll, Ph. D. Philadelphia, W. B. Saunders Co.,

1944. Pp. 699. Price, $7.00.

This is truly an epochal book, if we may so desig-
nate a work that marks the beginning of an era
in the medical history of Latin America, written
in English and for the first time interpreted in
its full significance as an aggregate of nations of
the same pai'ent stock, viewed as a whole without
special regard to their geographic or political limi-
tations. This book is also a monumental produc-
tion in the great scope of its encyclopedic survey
of the vast treasure of historic lore that has re-
mained too long buried and unexploited by the
literary gold diggers of the English tongue who
have not yet awakened to the reality of the mine
of medico-literary wealth that they have so signally
overlooked. Fortunately, medical literature and the
medical history of Latin America treated in the
aggregate and in bloc, as has been done so success-
fully in this book, have not suffered by the long
delayed recognition of their merit, for the man
had not yet appeared who could attempt this mag-
nificent but difficult enterprise, with all the quali-
fications necessary to carry it to a successful
realization. The rare combination of qualities for
such a task, as they are revealed in every page of
this book, are preeminently those of a scholar deep-
ly learned in the Spanish and other languages of
the Latin American peoples. A genuine sympathy
and inherent understanding of the people who
spoke them; a passionate interest in the work and
in the medical lore and literature of the medical
institutions and personalities in medicine and the
allied sciences in relation with the outside world.
All this on the one hand, and on the other, a
thorough mastery of English with a clear posses-
sion of its vernacular strength and graces of dic-
tion that would do justice to the idiomatic and
faithful interpretation of the Latin American
texts. As a result of years of tireless investigation
and zealous industry, in an environment most con-
ducive and satisfying for bibliographic research
and for the cultivation of inter-American relations,
the author, Dr. Aristides A. Moll, long known to
all in touch with Latin American affairs, as the
learned and most efficient Secretary-editor of the
Pan American Sanitary Bureau at Washington,
and advisor in tropical diseases to the Secretary
of State, has produced a book, which in its orig-
inality, literary quality and enormous wealth of
new and ordinarily inaccessible information on the
medical history and institutions of the Latin Amer-

ican countries has no parallel in English medical
literature. In this sense it remains unrivalled in
its own Latin American field, finding comparison
only in Garrison’s History of Medicine, which re-
mains the first, unique and greatest historic
product of American medical literature. Like that
master work, Dr. Moll’s Aesculpius in Latin Amer-
ica displays the meticulous thoroughness and
accuracy of its quotations and bibliographic refer-
ences ; in the chronology of notable events and most
useful “subject” and “author” indices, not forget-
ting the unique maps of the western hemisphere
with the geographical location and distribution of
the most conspicuous historic events associated
with Latin American explorations and personali-
ties. The illustrations are a very striking feature of
this book. They are far more numerous than in any
other texts of correlated interest. They are almost
all unusual and unfamiliar reproductions of scenes,
institutions and especially portraits, of outstanding
personalities in the Latin American medical world.
Altogether, they constitute a pictorial gallery, a
sort of Hall of Fame, which embraces the most
illustrious representatives of medicine in the Latin
American republics as they stretch all the way
from the Mexican border, south of the Rio Grande,
to the tip of the South American continent in Chile
and the Argentine.

The 699 pages of text include a remarkable in-
troduction which is a preview and a foretaste of
the vast store of learning that awaits the reader
as he enters into the text; a preview that would
certainly be appalling to any pretentious amateur
in historical research who would, unknowingly, at-
tempt to follow in the master’s footsteps and dream
of climbing to his stature. Three basic divisions
of the book follow the introduction. The first
covers the colonial period from the Columbian dis-
covery in 1492 to 1808, which is developed in 39
well nourished chapters. The period of Independ-
ence in 78 most fascinating sections, which deal
attractively with every phase of medical life in
Mexico, Central and South America and the West
Indies. The chronology, both medical and general,
begins with Columbus in 1492 and ends, year by
year in 1943 with the most notable events con-
nected with Latin American war relations with
inter-American cooperation in foreseeing Pan
American solidarity of the western hemisphere,
penicillin and other items of contemporary interest,
too numerous to mention.

The index of names (13 pages) is a veritable
“Who’s Who” in the medical hierarchy of the Latin
American countries.

Quite apart from its historic and bibliographic
value there is much to learn from the author’s
philosophy and his judicious and discriminating
but always friendly criticisms of Latin American
institutions and life.

88

Book Reviews

The medical people of Latin America will wel-
come this book with acclaim and well justified
pride in the fine showing of their “Hall of Fame”
and as a refutation of the alleged foreign dictum
that “Latin America is better in consumption than
in production.” In so far as North America and
the English speaking world are concerned, Dr.
Moll’s book will come as a revelation and a new
concept of Central and South American historic
wealth and of the immeasurable intellectual po-
tentialities that will soon find their greatest ex-
pansion in the unavoidable freedom of communica-
tion and aerial transportation of the post-war.

Finally, this reviewer predicts with certainty of
verification, that no American medical traveller
bent on a visit to the shrines of Aesculapius in
Latin America, will ever start on his journey with-
out a copy of Moll’s book under his arm as his
indispensable vade mecum.

Rudolph Matas, M. D.

Operative Oral Surgery : By Leo Winter, D. D. S.,

M. D., F. A. C. D., ScD. (Hon. LL. D. 2d ed.

St. Louis, The C. V. Mosby Company, 1943.

Pp. 1074, illus. pi. Price, $6.00.

The second edition of this important book pos-
sesses all of the merit of the first printing with
added material to meet the present emergency-
new chapters, bringing the treatise up to date
cover chemotherapy, shock, burns, war wounds,
dislocation and subluxation of the temporomandib-
ular articulation and skeletal fixation for treat-
ment of fractures.

The book is profusely illustrated, ranging from
the most elementary armamentarium and positions
of patients to technical procedures which are clear-
ly and adequately presented in successive stages.

There are shown, likewise, chemical, pathologic
and x-ray findings which illustrate with detailed
care the conditions so thoroughly described.

The section on fractures is particularly to be
commended. Accepted present methods are em-
phasized and both anatomic and physiologic prin-
ciples are stressed.

The author, in the new chapter on skeletal
fixation, very wisely describes various methods and
does not endeavor to influence the reader to his
own preconceived ideas or opinions. This reviewer
believes this to be the proper, broad-minded view
because of the wide difference in concept as well
as methods of application in this new means of
handling fractures of the jaw.

Chapter XIX on neoplasms in the oral cavity is
in keeping with the other sections of this well
balanced treatise and is divided into those of for-
eign and benign and malignant character, their
diagnosis and management.

While some principles of plastic repair and re-
construction are commented upon, reparatory
procedures of extensive character are not included
as they correctly belong to a different and highly
specialized field.

With so many years of experience as teacher,
clinician and operator there is perhaps no one
better qualified to produce a book of such magni-
tude on oral surgery and the character and com-
pleteness of the text justifies this statement.

The volume is unreservedly recommended to the
general surgeon, the dentist and the oral surgeon.
It should be of particular help to the dentists and
those in the armed forces called upon to handle
the facial and oral injuries of war.

Waldemar Metz, M. D.

Synopsis of Neuropsychiatry. By Lowell S. Snell-
ing, Sc. M., M. D., Ph. D„ Dr. P. H. St. Louis,
C. V. Mosby Co., 1944. Pp. 500. Price, $5.00.

At times in the past teachers in Medical Colleges
have discouraged use of compends and synopses.
But the rapidly widening scope of professional
knowledge and the necessity to step up perform-
ance and production, in the training of doctors,
has resulted in the appearance of numerous small,
condensed, factual books.

The author of this excellent manual has omitted
much of the unnecessary detail of the conventional
medical textbook. He has written a simplified,
systematic coverage of neuropsychiatry which will
be of inestimable value to the specialist who wishes
to review his subjects briefly and in which the
student can secure a quick guide for diagnosis and
treatment and a substantial knowledge of the sub-
jects so admirably presented.

Enough neuro-anatomy and neuro-physiology is
included to render the organic neurological syn-
dromes easily comprehensible. Sufficient psycho-
pathology, abnormal psychology and psychoanalysis
are presented to provide a background for the un-
derstanding of functional nervous and mental dis-
orders. In view of Doctor Selling’s eminence in
medicolegal psychiatry his “medicolegal” comments
are most interesting and valuable.

It hardly seems possible that so much authorita-
tive information could be put in so small a book
conveniently arranged as a portable, ready refer-
ence. This book is a splendid one in every way.
Anyone interested in neuropsychiatry will cer-
tainly profit greatly by using it.

C. P. May, M. D.

Book Reviews

89

The American Illustrated Medical Dictionary : By
W. A. Newman Dorland, A. M., M. D., F. A.
C. S. Philadelphia and London, W. B. Saunders
Company, 1944. Pp. 1,668. Price; $7.50.

The 20th edition of this very well known medical
dictionary has been considerably revised and en-
larged. Dr. Dorland in revision of this present
edition collaborated with Dr. E. C. L. Miller of
Richmond and a group of other individuals who
have lent aid and made suggestions and otherwise
helped in the revision of the book. To all these
men Dr. Dorland has given credit to this 20th
edition. It hardly seems necessary to offer criti-
cism of a book that has been a standard publication
since 1900. As a matter of fact, the only real
criticism is that this dictionary is getting to be
almost the size of a standard English dictionary.
The only suggestion to make to reduce the size
would be to reduce materially the anatomical con-
tents, such as the table of arteries and the listing
of the veins. Informations concerning the vascular
system can be readily obtained from any anatomy
book. It hardly seems necessary to put in colored
cuts. Certainly the one on biliary calculi is not
worth the space that it takes up in a volume that
is already somewhat oversized.

These criticisms are minor and trivial. The Dor-
lands have done such excellent work in preparing
the innumerable editions of this dictionary that a
volume or a new edition appears every little while,
attesting to the popularity of the book and to its
well worth while character.

J. H. Musser, M. D.

A Dynamic Era of Court Psychiatry, 1914-44, ed.
by Agnes A. Sharp, M. A., Ph. D. Chicago,
Psychiatric Institute of the Municipal Court of
Chicago. 1944. Pp. 149. Gratis.

The purpose of ths book is twofold : to record
the first thirty years of service of the Psychiatric
Institute of the Municipal Court of Chicago, and to
present scientific facts of Court Psychiatry with
some prediction, as we face a period of readjust-
ment perhaps more confused than any we have
yet come through. The numerous articles appear-
ing in this valuable report emphasize the fact
that data are rapidly accumulating on Court Psy-
chiatry and reveal a growing appreciation of the
enormous value of psychological medicine in at-
tempting to dispose of the problems of human con-
duct which are ever coming before the courts to be
solved or disposed of.

Everywhere, each year, thousands of minor in-
fractions of the law by mentally ill persons bring
them to the notice of a court. To judge these in-
dividuals purely on the basis of their quasi-criminal
conduct could result in miscarriage of justice end-

ing in many of these persons being sent to institu-
tions not equipped to handle them.

Many of the crimes committed by mentally ill
persons are peculiar to the mental disturbance
itself. When such persons are examined and re-
ported upon by The Institute an enlightened ju-
diciary is properly guided in its evaluation of
behavior disturbances, particularly of the bizarre
types of mental manifestations so frequently seen
in psychotic individuals. In this way many cases
of incipient mental disorder are discovered and
proper measures may be taken to endeavor to cor-
rect them.

To examine and evaluate the extensive and valu-
able material presented in this small volume is
somewhat of a job and it cannot be adequately
covered in a brief review. Use of this book will
afford great help to anyone interested in the
medicolegal relations of psychiatry.

C. P. May, M. D.

Rorschach's Test. Vol. 1. Basic Processes: By

Samuel J. Beck, Ph. D. New York, Grune and

Stratton, 1944. Pp. 223. Price, $3.50.

Doctor Beck, whose “Introduction to the
Rorschach Method” in 1937 gave students a valu-
able manual of procedure, now reports “a field
excursion into Rorschach associations” to “demon-
strate the processes used in evaluating Rorschach
test responses.” His contention has always been
that the Rorschach method is objective, and cap-
able of being applied by anyone willing to undergo
the required prerequisite rigorous training. As an
aid in such training, he has in the present book
provided students “with a moderately stable frame
of reference.”

No attempt at interpretation is made in “Basic
Processes”. Individual responses drawn from nor-
mals, mildly disturbed, and definitely pathologic
cases are cited verbatim, scored, and the reasons
for scoring cited in detail. Separate chapters are
devoted to the various basic problems in scoring.
Thus it makes possible comparison of response
summaries on a quantitative basis, apart from the
psychologic interpretation.

Although the scoring is but slightly modified
from the 1937 version, some of the English symbols
have been discarded in favor of those used in the
Lemkan-Bronenberg translation of the original
“Psychodiagnostik” by Herman Rorschach. The
numbering system used for the details is a com-
plete revision of the 1937 system, and accordingly
must be patiently mastered by students of the
Rorschach method.

Both student and expert will find “Basic Proc-
esses” an indispensable reference book, and will
regard it as a contribution to the development of

90

Book Revieivs

the Rorschach technic as important as is Doctor
Beck’s “Introduction to the Rorschach Method.”

Marion McKenzie Font.

A Hundred Years of Medicine-. By C. D. Haag-

ensen, M. D., and Wyndham E. B. Lloyd, M. D.

New York, Sheridan House, 1943. Pp. 444.

Price, $3.75.

This is really a delightful book which in reading
will afford a great deal of pleasure to any one
interested in medicine. It is written primarily
for the lay individual but the physician, when, as
and if he ever has time for light reading, will de-
rive considerable benefit from its perusal; he will
attain a great dea lof historical information which
will recall to his memory most clearly the out-
standing contributions of medicine, and its many
ramifications, in the past hundred years.

The book, while divided into sections and chap-
ters, is really a series of essays on a variety of
subjects which have been of paramount interest
during the last century so that the individual chap-
ters are thus more or less complete in themselves.
The four sections of the book have to do with
“medicine up to 100 years ago, medical science dur-
ing the last 100 years, surgery during the last 100
year” and the fourth and last, “the new social
aspects of medicine.” The first section has largely
to do with medicine as it existed 100 years ago,
the next two sections describe the astounding ad-
vances made in medicine and surgery during this
period of time and the last section in part forecasts
what medicine may be in the future.

The book is so interesting and so well written
that it makes for easy reading. The factual data
are accurate. The format of the volume is excel-
lent and the numerous illustrations are well se-
lected and clearly reproduced.

J. H. Musser, M. D.

Poliomyelitis ; The Relation of Neuroscopic Strep-
tococci to Epidemic and Experimental Poliomyc-
Hties Virus, Diagnostic Serologic Tests and
Serum Treatment : By Edward C. Rosenow.

New York, International Bulletin for Medical
Research and Public Hygiene, 1944. Vol. A44.
Pp. 87.

In this monograph Dr. Rosenow has reviewed
(with bibliography) his work over a period of
twenty-seven years concerning the role of strepto-
cocci in poliomyelitis. One is appreciative of the
courtesy of the editors of the International Bulle-
tin in making it possible for this comprehensive
summary of the data to be published as well as
for the high quality of the typography and repro-
duction of photographic material. However, after
reading the monograph one is still left unconvinced
of the validity of the claims which are made,

despite an entire willingness to accept the author’s
honesty and sincerity. This skepticism is due
in large part to statements which are in complete
contradiction to the overwhelming bulk of evidence
obtained by many other, equally experienced work-
ers. Some examples seem noteworthy.

1. Dr. Rosenow has found streptococci by smear
in the spinal fluids of 54 per cent of persons with
acute epidemic poliomyelitis and by culture in
dextrose-brain-broth medium in 38 per cent of
cases (p. 20). This high incidence of positive find-
ings is entirely opposed to the generally accepted
view that it is useless to seek to isolate the agent
of poliomyelitis from the spinal fluid of either
pre-paralytic or paralytic cases, as such attempts
are almost invariably unsuccessful. If the strepto-
cocci found by Dr. Rosenow in the spinal fluid do
represent the agent of poliomyelitis, it should be a
relatively easy matter to reproduce the disease by
transfer of this material to monkeys; this is not
the case.

2. Dr. Rosenow’s neurotropic streptococci pro-
duce extreme flaccid paralysis upon inoculation
into guinea pigs and rabbits (pp. 32-33 and 58-59),
whereas other workers have repeatedly observed
that the infective agent in the brain and cord of
poliomyelitic humans or monkeys regularly fails to
affect rabbits or guinea pigs.

3. In Rosenow’s hands, 8 per cent of brain and
cord emulsions from monkeys with typical polio-
myelitis yielded positive cultures for streptococci
when diluted as high as 10 -20 (p. 20). A simple
calculation will convince anyone that, whether the
agent of poliomyelytis were present in the form of
streptococci or in the form of a filtrable virus
with diameter of approximately 8 mu (as be-
lieved by workers in the virus field), it would be
physically impossible for 10 20 such particles to be
contained in a volume of one cubic centimeter.

4. According to Rosenow the intracerebral in-
jection of dead arthritis streptococci into monkeys
results in their prompt disappearance from the
spinal fluid and their appearance, often in con-
siderable numbers, in the articular fluid; the in-
tracerebral inoculation of dead neurotropic strepto-
cocci, on the other hand, as followed by no penetra-
tion into the joint fluid (p. 56). It is difficult to
accept this observation as due to other than uncon-
trolled experimental factors.

5. Dr. Rosenow has been able to isolate a trans-
missible filtrable agent producing typical symp-
toms and lesions of poliomyelitis from strains of
streptococci derived from sources wholly unre-
lated to poliomyelitis such as malignant endocardi-
tis and from a case of postoperative persistent
hiccup and bronchopneumonia (p. 66).

6. Eighty-seven per cent of persons in the early
stages of acute poliomyelitis gave erythematous

Book Reviews

91

cutaneous reactions to be a bacterial antigen pre-
pared from poliomyelitis streptococci (p. 46) ; a
similar percentage (87) of persons in the acute
stages of poliomyelitis yielded positive cutaneous
reactions to the euglobulin fraction of strepto-
coccic antiserums (p. 49). Rosenow’s finding, that
the great majority of poliomyelitis patients react
both to streptococcal antigen as well as to anti-
streptococcal antibody while in the same stage of
the disease, is almost unique since in nearly all
other known instances patients in any particular
stage of a disease are found to react to either anti-
gen or antibody but not to both concurrently.

While it is fortunate that this review has been
made available, since it gathers together data pre-
sented by Dr. Rosenow in numerous publications
over many years, the case for the role of strep-
tococci in poliomyelitis does not yet seem proved.

Morris F. Shaffer, D. Phil.

PUBLICATIONS RECEIVED
American Medical Association, Chicago: New

and Nonofficial Remedies, 1944. Reports of the

Council on Pharmacy and Chemistry of the Ameri-
can Medical Association for 1943.

Charlotte Medical Press, Charlotte, N. C.: Me-

tastases, by Malford W. Thewlis, M. D.

The Commonwealth Fund, New York: Mosquito

Control, by William Brodbeck Herms, Sc. D. and
Harold Farnsworth Gray, Gr. P. H.

Grune and Stratton, Inc., New York: Arti-

ficial Pneumothorax in Pulmonary Tuberculosis,
by T. N. Rafferty, M. D. The Electrocardiogram,
by Louis H. Sigler, M. D., F. A. C. P.

J. B. Lippincott Company, Philadelphia: Fer-

tility in Men, by Robert Sherman Hotchkiss, B. S.,
M. D. Fertility in Women, by Samuel L. Siegler,
M. D„ F. A . C . S.

Charles C. Thomas, Springfield, Illinois: The

Pathogenesis of Tuberculosis, by Arnold R. Rich,
M. D. Technic of Electrotherapy and Its Physical
and Physiological Basis, by Stafford L. Osborne,
M. S., Ph. D. and Harold J. Holmquest, B. S.,
B. S. (M. E.)

UNITED STATES WAR

BONDS and STAMPS

Yol. 97

SYMPOSIUM ON TROPICAL
MEDICINE*

INTRODUCTION

TROPICAL MEDICINE IN THE UNITED

STATES AS A RESULT OF THE WAR

ERNEST CARROLL FAUST, Ph. D.

New Orleans

In a broad sense tropical medicine is not
a separate branch of medicine. Persons
who have lived or visited in the Tropics at
times come to the physician back at home
with this dreadful appeal : “Doctor, I have
a rare tropical disease. Can. you cure me?”
Actually there are very few diseases, such
as African trypanosomiasis and yaws,
which are peculiar to hot climates. Most
diseases of tropical areas are also mildly
endemic, or potentially endemic or epi-
demic in temperate zones, given only the
necessary epidemiologic setting. Likewise,
most of the diseases of temperate climates
occur in the Tropics.

It is true, however, that warm climates
produce an unusually satisfactory setting
for the propagation of human disease, due
to the following conditions :

(1) A greatly reduced threshold of re-
sistance of human population to the
development of etiologic agents of
disease.

(2) Poor personal hygiene and group
sanitation of native peoples.

(3) Unusually fine opportunities for the
breeding of insects and other trans-
mitters of disease agents, and

* Conducted by the Department of Tropical Med-
icine, Tulane University of Louisiana, New Or-
leans, La., before the Orleans Parish Medical
Society, January 24, 1944.

No. 3

(4) The frequently enhanced virulence
of the etiologic agents, especially for
non-immune persons or groups en-
tering hyperendemic areas.

Thus, tropical medicine may be properly
considered as the science and practice of
medicine in warm climates.

There is no need to discuss cosmopolitan
diseases prevalent in warm climates, but it
is desirable to consider some of the more
common diseases of the Tropics which are
less prevalent in our own country and their
importance to us, now and in the years im-
mediately ahead.

o

THE DISTRIBUTION AND EPIDEMI-
OLOGY OF IMPORTANT TROPICAL
DISEASES OF THE WAR
AREAS

ALBERT MILLER, Ph. D.

New Orleans

The purpose of this presentation is to
serve as an introduction to the discussions
to follow regarding some important dis-
eases existing in the present war areas that
may be either introduced into, or increased
in the United States as a result of military
travel and commerce. The salient features
of the epidemiology and geographical dis-
tribution of these diseases will be briefly
reviewed.

The present 'active combat areas are in
Europe, with ground operations in western
Russia and in central Italy, and in the
southwestern Pacific region, particularly
New Guinea and the neighboring islands.
Activity will extend into central Europe,
into the vast tropical areas now occupied
by Japan, including Burma, Thailand,
French Indo-China, coastal China, the Ma-

New Orleans Medical

and

SEPTEMBER, 1944

94

Miller — Symposium — Tropical Medicine

lay States, the Netherland East Indies, the
Philippine Islands, and into Japan itself.
Troops in these areas will be exposed to
diseases that are absent or of relatively low
incidence in the United States. Equally
important from this point of view are the
widely scattered tropical and subtropical
localities where American forces are now
stationed outside the combat zones proper,
hence the West Indies, Central America, the
Galapagos Islands, British Guiana, Brazil,
North and Central Africa, the Near East,
India, free China, Australia, New Zealand,
Fiji, Samoa, and Hawaii.

The main trade routes between North
America and Europe (North Atlantic),
Brazil and Africa (South Atlantic),
through the Mediterranean and Red Sea,
across and around Africa to India, and
from the Pacific Coast of North America
to Australia and the Pacific islands all af-
ford opportunity for the rapid spread by
ship or airplane of disease in returning
troops or in arthropod vectors. Many dis-
eases normally confined to, or particularly
virulent in tropical areas may by these
means be carried back to the United States
as a result of the greatly increased traffic
consequent upon the conduct of the war. It
is, therefore, of interest to summarize
briefly the cause, manner of dissemination,
and circumstances favoring the occurrence
or introduction of diseases potentially capa-
ble of assuming greater importance in the
United States by importation from foreign
endemic foci.

MALARIA

Malaria is caused by certain blood-inhab-
iting protozoa ( Plasmodium vivax, P. mala-
riae, P. falciparum, and P. ovale ) which at-
tack man only. It is normally transmitted
through the bites of anopheline mosquitoes
that have become infected by parasites in-
gested with an earlier blood meal.

Man possesses no absolute natural or
acquired immunity, and no means of vacci-
nation has been perfected. Recurrent at-
tacks and relapses which may occur several
years after infection make the victim a
potential source of the disease for extended
periods. Suppressive drugs (quinine, ata-

brine) hold the parasites in check only tem-
porarily.

The dissemination of the disease requires
the presence of the parasite in man, suffi-
cient warmth, humidity and rainfall for the
propagation and survival of the mosquito
transmitters, and suitable water to serve as
breeding places within flight range (one to
five miles) so that sufficient anophelines
are present to enable continued transmis-
sion. Natural breeding places may be aug-
mented as a result of faulty agricultural or
engineering practices that produce shallow
standing water. Exposure to bites of in-
fected mosquitoes is most likely to occur in
poorly constructed or screenless houses, or
outdoors after sundown. Failure to rid the
blood of parasites as a result of inadequate
treatment provides a source of infection for
the mosquitoes and the community.

Though already endemic in the southern
United States, the incidence and severity of
malaria may be increased by the importa-
tion of more virulent strains of malaria
parasites in man. More efficient mosquito
vectors may also enter the country by ship
or airplane and become established, if pre-
cautionary measures are not continually
enforced.

Malaria is worldwide in distribution in
the Tropical Zone and warmer parts of the
Temperate Zones, with the heaviest foci in
Central America, northern South America,
northern and equatorial Africa, central U.
S. S. R., coastal India, and the East Indies.
The Pacific combat area is highly malarious
and the disease is common in the Italian
battle zone. Malaria is not indigenous and
anopheline mosquitoes are said to be absent
in the Pacific islands southeast of the New
Hebrides, for example, in New Zealand,
Guam, Tahiti, Samoa, Fiji, and Hawaii.

THE ENTERIC INFECTIONS

The important enteric infections include
amebiasis, caused by the protozoon End-
amoeba histolytica, bacillary dysentery,
caused by Shigella spp., typhoid fever,
caused by Eberthella typhi, and cholera,
caused by Vibrio comma. All are human
diseases transmitted through fecal contam-
ination of food or water by human carriers,

Miller — Symposium — Tropical Medicine

95

by insects (flies, roaches, ants) which
carry the microorganisms mechanically, or
through faulty sewerage systems.

Man may perhaps have some natural or
acquired resistance to amebiasis and bacil-
lary dysentery, though immunity as a result
of infection is questionable and there is at
present no effective means of vaccination.
Typhoid and cholera infections usually con-
fer good immunity, and vaccination is ef-
fective.

These diseases originate from infected
patients and their dissemination is favored
by poor sanitation, faulty sewerage and
water supply, inadequate inspection of food
handlers, inadequate control and protection
against flies and other insects (faulty gar-
bage disposal, inadequate screening, ex-
posure of food), and crowding in poorly
sanitated quarters. The use of human feces
as fertilizer for food crops may be an im-
portant source of infection. Warm weather
is conducive to dissemination by favoring
the propagation of insect carriers as well as
the multiplication of bacteria causing the
diseases.

The enteric infections are worldwide in
distribution, except cholera which occurs
mainly in India and the Orient and is not
endemic in the United States. Although
the other diseases are already present here,
the possibility exists that more virulent
strains of the pathogens may be introduced
into the United States from the Tropics by
the migration of infected human beings
from endemic foci.

THE TYPHUS GROUP OF FEVERS

The rickettsioses (typhus and spotted
fevers) are caused by rickettsia micro-
organisms transmitted by blood-sucking
arthropods. Epidemic typhus caused by
Rickettsia protvazeki var. protvazeki , is
transmitted from man to man by human
lice through contamination of skin abra-
sions or mucosa with fresh or dry louse
feces or by crushing lice, and probably also
by inhalation of dry rickettsias. Endemic
or rat typhus, caused by R. protvazeki var.
mooseri, is found in domestic rats and mice
and is transmitted to man by rat fleas via
infected flea feces. Spotted fever, caused

by R. rickettsi, is transmitted by the bites
of ticks, and Oriental mite typhus (R. ori-
entals) by the bites of larval mites (chig-
gers, Trombicula spp.).

There is no evidence of natural immunity
to these infections, but acquired immunity
follows infection or specific vaccination
(partial in spotted fever).

Circumstances favoring infection are cor-
related with the habits of the vectors.
Epidemic typhus occurs in louse-infested
populations where unhygienic conditions
exist as a result of poverty, crowding, war
or famine, and is favored by cold weather
conducive to increased lousiness. Rat typhus
occurs sporadically through exposure to
fleas in rat-infested dwellings or working
quarters during warm weather. Spotted
fever is contracted in warm weather
through outdoor exposure to tick bites dur-
ing occupation or recreation in rural or
suburban locations, or from ticks carried
indoors by dogs. Mite typhus likewise is
contracted through outdoor exposure to
chigger bites in endemic regions.

Rat typhus and spotted fever are endemic
in the United States. Epidemic typhus is
absent and lice are uncommon, but impor-
tation in human beings, lice, or perhaps dry
louse feces in clothing is possible. Mite
typhus does not occur here, and it is un-
known whether our common chiggers could
serve as vectors.

Louse-borne typhus occurs in Central and
South America, Africa, Europe (especially
in the Balkans and Russia), and Asia.
Flea-borne typhus is present in all warm
regions, spotted fever in North America,
South America, Africa, and Europe, while
mite typhus is confined to the Far East
and Pacific area.

YELLOW FEVER

Yellow fever is caused by a filtrable virus
which may be found in man and probably
in wild forest animals in South America and
Africa. The epidemic urban form of the
disease is transmitted by the bites of the
domestic yellow fever or “Stegomyia” mos-
quito, Aedes aegypti, and the endemic “jun-
gle” form by various wild forest mosquitoes.

Man’s natural resistance to infection is

96

Miller — Symposium — Tropical Medicine

probably variable, with permanent immu-
nity following infection and for at least four
years after vaccination.

The occurrence of the disease depends
upon the presence of the virus in man or
forest animals and the presence of suscep-
tible mosquitoes to serve as transmitting
agents. For urban epidemics, the yellow
fever mosquito must be at least moderately
common, breeding in or around 5 per cent
or more of the dwellings. This is favored
by the occurrence of standing water in un-
disturbed artificial receptacles about the
home (flower pots, jars, cisterns, clogged
roof-gutters, and the like) during the warm-
er seasons of the year. The yellow fever
mosquito bites mainly during the day in-
doors, while other transmitters in the forest
are outdoor daytime-biters, protection de-
pending upon the use of proper screens,
netting, repellents, or sprays. Unscreened
patients may serve as infectors of mosqui-
toes during the early stages of the disease
when the virus is circulating in the blood
(from ten hours before to four days after
the onset of symptoms).

While yellow fever is not endemic in the
United States, the yellow fever mosquito is
common in the South and could readily
spread the virus if it were introduced in
man or infected mosquitoes from endemic
areas by fast transports, especially air-
planes.

The disease is enzootic, and in the past
has been frequently epidemic, in tropical
regions of South America and Africa.
The yellow fever mosquito is distributed
throughout the Tropics, including the Pa-
cific and Indian areas where it constitutes
a potential vector if the disease should be
accidentally introduced in those regions.

Two other virus diseases, dengue and
sandfly fever, deserve passing mention.
The former is also transmitted by Aedes
aegypti and related mosquitoes throughout
the warmer parts of the world. The latter
(also called Pappataci or Phlebotomus fe-
ver) is transmitted by sandflies of the
genus Phlebotomus in areas extending from
the Mediterranean region to South China.
Sandflies of this kind are rare in the United
States.

1 1 E MO FLA G E LI .AT E INFECTIONS

The hemoflagellate infections include the
leishmaniases (kala azar, Oriental sore, and
South American espundia), caused by pro-
tozoa of the genus Leishmania, and the try-
panosomiases (African sleeping sickness
and South American Chagas’ disease),
caused by protozoa of the genus Trypano-
soma. These parasites are all found in
man; those causing kala azar and Chagas’
disease are also found in the dog, and the
trypanosomes occur in domestic and wild
animals in Africa and South America.

The leishmaniases are transmitted by
sandflies ( Phlebotomus spp.) through the
bite or through crushing the insect on the
skin, or sometimes by direct contact with
the cutaneous lesions. African trypanoso-
mias is transmitted by the bite of tsetse
flies ( Glossina spp.) and Chagas’ disease by
contamination of the skin or mucosa with
the feces of infected blood-sucking triato-
mid bugs (family Triatomidae) .

There is no evidence of natural immunity
to these diseases, but in Oriental sore nat-
ural infection or vaccination confers immu-
nity and in African trypanosomiasis arseni-
cal drugs may afford some protection.

When the parasites are available, their
dissemination depends upon an abundance
of the insect vectors, which in turn requires
favorable breeding conditions (damp de-
bris, crevices, warmth and humidity for
sandflies ; shaded dry soil, brush, trees,
game and domestic animals for tsetse flies;
and poor building construction and rural
living conditions for triatomid bugs). The
tsetse flies are outdoor daytime biters, while
sandflies and triatomids feed mainly at
night, both in houses and outdoors. Warm
weather increases the activity of insects and
thus favors transmission of the diseases.

Hemoflagellate infections are not endemic
in man in the United States, but the try-
panosome causing Chagas’ disease is pres-
ent in rodents and triatomid bugs. Sand-
flies are rare and tsetse flies completely
absent, and it is questionable that the dis-
eases would become established here.

The two types of trypanosomiases are re-
spectively limited to tropical Africa and to
Latin America. The three types of leish-

Miller — Symposium — Tropical Medicine

97

maniases occur in Central America, South
America, the Mediterranean region, Africa,
India, and China.

FILARIASIS

Filariasis of different types is caused by
several species of parasitic roundworms,
the filaria worms, which are transmitted
from man to man by mosquitoes and other
blood-sucking flies. Bancroft’s filariasis,
caused by Wuchereria bancrofti and a re-
lated infection due to W. malayi are trans-
mitted by the bites of mosquitoes, including
domestic mosquitoes ( Culex spp., Aedes
spp.). Onchocerciasis, caused by Onchocer-
ca volvulus, is transmitted by blackflies
( Simulium spp.). Loaiasis, caused by Loa
loa , is transmitted by deer flies ( Chrysops
spp.).

There is no natural or acquired immunity
to these infections, no vaccination nor spe-
cific therapy is yet available, and the in-
fections run a chronic course of many years’
duration.

These diseases may be contracted wher-
ever the parasites are present in the popu-
lation and the specific insect transmitters
are common as a result of suitable breeding
places and warm weather favoring their
propagation and activity. Infection in-
volves exposure to mosquito bites in poorly
screened quarters or outdoors, or to the
bites of other vectors in their natural
haunts near swamps or streams in endemic
regions.

The diseases are not endemic in the
United States, but suitable vectors are com-
mon and may constitute a potential hazard
if the parasites are introduced by infected
men returning from infected areas. Ban-
croft’s filariasis is widespread throughout
the Old World and New World Tropics, in-
cluding all the Pacific islands except Ha-
waii. Wuchereria malayi occurs in India,
China, and the Dutch East Indies. Oncho-
cerciasis is endemic in equatorial Africa,
Guatemala, and southern Mexico, and
loaiasis in Central Africa.

SCHISTOSOMIASIS

Schistosomiasis is caused by three closely
related species of parasitic worms, the blood

flukes ( Schistosoma haematobium, S. man-
soni, and S. japonicum) , which inhabit the
blood vessels of man and, in the Orient, of
domestic mammals and rodents. The eggs
passed in feces or urine hatch in water, and
the larval worms infect specific types of
snails in which they multiply and develop
into forms that later escape into the water
and penetrate the skin of man during im-
mersion.

Natural or acquired immunity is un-
known, and infection depends upon expos-
ure to “infected water” during wading,
bathing, or washing.

These diseases occur where infected ex-
creta are deposited in water, either directly
or via sewage, in which there are suscep-
tible snails. Their dissemination is favored
by warm weather, agricultural practices
like irrigation canals and rice cultivation,
and living habits involving deposition of
excreta in the water used for these pur-
poses or for outdoor laundering, bathing,
or religious ceremonies.

Schistosomiasis is not endemic in the
United States, but it is possible that sus-
ceptible snails may be present. The disease
is present in the West Indies and northern
South America ( S . mansoni) , Africa (S.
mansoni, S. haematobium), the Near and
Middle East (S. haematobium) , and the Far
East, including the Philippines and Celebes
( S . japonicum) . The disease could be im-
ported in infected human beings, and snail
hosts may be introduced artificially or
spread through irrigation projects.

With regard to other potentially impor-
tant “tropical” diseases in the war areas,
mention may be made of bubonic plague
(transmitted by rat fleas), relapsing fever
(louse- and tick-borne), yaws and bejel
(transmitted by contact and probably by
flies), and hookworm infection (contracted
by contact with infested soil). With the
exception of louse-borne relapsing fever,
yaws and bejel, these are already endemic
in the United States. As in the diseases
discussed above, an increase of their inci-
dence or severity here would depend largely
upon conditions favorable for their trans-
mission by arthropod carriers.

98

Walker — Symposium — Tropical Medicine

MALARIA

A. J. WALKER, M. D.

New Orleans

That malaria will be introduced into the
United States now and after the war by
troops and other personnel, returning from
highly endemic areas, is a foregone conclu-
sion. At the same time, different and pos-
sibly more virulent strains of plasmodia
may also be imported.1 The effect of such
a happening in a non-malarious area having
suitable vectors may readily be imagined.

Of special importance to localities where
anophelines are already prevalent are
chronic relapsing cases as potential sources
of infection to the local mosquitoes. While
assuming that some species of mosquitoes
are at present refractory to imported
strains of malaria,2 it is possible that long
and repeated exposure to such strains may
result in adaptation to them.

Furthermore, it would indeed be catas-
trophic if a mosquito species, similar to
Anopheles gambiae transferred from Africa
to Brazil in 1929, 3 should elude the sanitary
precautions already in effect in this coun-
try.

These are only two of the broad problems
of the post-war period in which it has been
said that no place in the world will be more
than 60 hours from the nearest airport.
This prophecy has already been fulfilled.

This brings us to consider the individu-
al patients who will be appearing in the of-
fices of physicians throughout the country
in ever increasing numbers. In addition to
those who have symptoms, there is also the
group of individuals who have been taking
prophylactic quinine (or atabrine), which
maintains symptoms at a subclinical level.
The term suppressive medication is more
desirable, for, when it is discontinued, there
is the likelihood that a person with malaria
will develop clinical manifestations.

Irrespective of the presenting symptoms,
whether febrile or afebrile, persons, who
have resided in areas where malaria is en-
demic or hyperendemic and are not well, are
entitled to have suitable diagnostic exami-
nations of their blood.

The severest forms of malaria have no

resemblance whatever to the usual concep-
tion of the disease, as its manifestations can
be most protean in character. I propose to
mention briefly a few cases which illustrate
this point, with special reference to those
which had a fatal termination. It is indeed
discouraging, in places where medical at-
tention is available, that in this day and
age men are continuing to die from malaria
— a specific disease, for which there are
specific remedies.

In order to emphasize the bizarre nature
of the symptomatology I would like to refer
to a number of cases, three of them in my
own experience, in which other diseases are
mimicked.

In Trinidad, a young adult oilfield work-
er and an elderly English lady were seen by
the same physician within ten days. Both
complained of attacks of pain in the gall-
bladder region and of fever in the after-
noon. The physician had seen several such
cases, and in spite of steadily rising tem-
peratures, he persisted with only sympto-
matic treatment. In each case, vivax ma-
laria was diagnosed by the daily thin blood
smear.

In a well-equipped hospital, word was re-
ceived to prepare the operating room for an
“acute abdomen” (perforated gastric ul-
cer?), which was being sent in by special
launch. The patient arrived packed in ice
bags. He had a generally rigid abdomen
with moderate temperature, a rapid pulse
and a very anxious expression. Vivax ma-
laria was demonstrated by a routine exami-
nation of the blood while a white blood
count was being made, which resulted in his
receiving intramuscular quinine rather than
an exploratory laparotomy.

A ship’s steward complained of mild
diarrhea and abdominal cramps. Examina-
tion of the feces showed only an occasional
red blood cell, leukocytes and epithelial cells.
Three such examinations were made before
the blood was examined. Under atabrine
treatment the diarrhea disappeared and
further symptoms of falciparum malaria
did not develop.

An even more severe type of intestinal
manifestation is shown in the report of the

Walker — Symposium — Tropical Medicine

99

German prisoner-of-war who was admitted
to a hospital with a diagnosis of dysentery
of two months’ standing. A thin smear of
his blood revealed no parasites on October
sixth. No further examination of his blood
is recorded but he died on October 11 of
cerebral malaria.

At the beginning of a voyage requiring
two or three months from Aden, at the
southern end of the Red Sea, to Freetown,
West Africa, the mate of a cargo ship sail-
ing around Africa, sought medical aid for
vague gastric symptoms in five ports-of-
call, and received prescriptions for alkalies.
In one port, the physician made a careful
physical examination and advised the re-
moval of practically all of his teeth which
were carious. In desperation the patient
had all of his teeth removed and subsisted
on liquid and soft diet for the rest of the
journey. Arriving at Freetown he encoun-
tered a malaria-conscious physician, quar-
tan malaria was diagnosed and treated, and
improvement in his condition was apparent
within five days.

Details have recently been recorded of
eight cases of malaria in persons returning
to this country within the past year from
such tropical areas as cited above.4

A welder, returning to the United States
from East Africa, waited for transporta-
tion in Accra, on the Gold Coast for about
one week. He had a chill on arrival in
Miami by plane on August 29. Three days
later he consulted a physician for upper
respiratory symptoms and was admitted to
a hospital on the following day in a deep
stupor; the temperature was 104° F., with
approximately 50 per cent of the red blood
cells showing P. falciparum. Treatment
was started but he died of cerebral malaria
eight days after landing in this country.

Another welder en route from Africa by
plane also stopped for several days in Accra,
reaching this country on February 4. On
February 8, he had a routine clinical exami-
nation with no abnormal findings. There
was no examination made of the blood. (In-
deed it is doubtful if parasites could have
been demonstrated in his blood as he was
in the incubation period.) On February 15,

he had chills, generalized aching, headache,
nausea and vomiting, profuse perspiration
and a temperature of 100° F., which re-
sulted in a provisional diagnosis of grippe.
The patient seemed to improve the follow-
ing two days, then suddenly became worse.
He was admitted to the hospital on Febru-
ary 18 with a temperature of 104° F., leu-
kocytes 3,400, with no malaria parasites in
the thin blood smear. On February 19 the
patient became delirious, the temperature
was 104° F., and he went into coma. Para-
sites were then found but it was too late
for the intravenous quinine treatment ad-
ministered and the patient died on Febru-
ary 21. The six other cases in this series
with more fortunate results showed one or
more of the following symptoms : fever,
chills, pain in the chest, upper respiratory
symptoms, labial herpes, vomiting and diar-
rhea and blackwater fever. In one instance
the diagnosis was suggested by the patient
himself.

Since the above cited cases all give a his-
tory of having been in the Tropics, one
might be very prone to say, “Well, it can’t
happen here,” but the following case never
left the confines of the United States. A pa-
tient was admitted to a hospital on Septem-
ber 21, disoriented, irrational, and deeply
jaundiced. The history was that his illness
had been provisionally diagnosed as influen-
za on September 12, with a temperature of
104.8° F. He was admitted to a hospital
on September 18 for three days, during
which time the temperature was never over
100° F., the leukocytes were 7,000; a differ-
ential count was made without mention of
parasites being found. Extensive blood
chemistry was carried out on September 21.
but again no mention is made of a search
for parasites. The following day he went
into coma and died. In the postmortem
blood approximately one in every 10 red
blood cells was found to be parasitized —
falciparum malaria.

Falciparum or estivo-autumnal malaria is
by far the most important as it can fre-
quently be fatal, wherees vivax or benign
tertian mal'aria is pronelto relapse^ ana quar-
tan malaria may become chronic.

100

Walker — Symposium — Tropical Medicine

The suggestion has been made regarding
the issuing of a card of instructions to pas-
sengers and crew members of all aircraft
returning from the Tropics in which they
are warned to obtain blood examinations for
malaria at the onset of any symptoms.

The broad problem remains an epidemio-
logic one.

DIAGNOSIS

The diagnosis is made by demonstrating
the parasite in the blood, which is most
readily done by means of the thick film, a
practice which should, ideally, be routine.
If malaria is actually suspected and the first
examination is negative, it should be re-
peated at intervals of twelve hours for a
period of three days.

For those not familiar with the diagnosis,
I should like to recommend a most useful
and valuable manual which is available,
from the Superintendent of Documents,
Washington, D. C., (price, 30 cents.) It is
Bulletin No. 180 of the National Institute of
Health — “Manual for the Microscopic Diag-
nosis of Malaria.” It has numerous plates
showing the appearance of parasites in both
thin blood smears and thick blood films.

The edition available hitherto does not
contain directions for Field’s rapid stain-
ing methods which is here briefly summar-
ized and is soon to be demonstrated. For
those who have experience with thick film
preparations this stain is recommended as
a rapid, efficient and simple office proce-
dure which may be carried out while the
history and temperature are being taken.

Preparation of Field’s Stain.

Disodium hydrogen phosphate crystals 25.0 gm
(if anhydrous 10.0)

Potassium dihydrogen phosphate 12.5 gm
Distilled water 1,000 ml.

For “Solution A”

add to 500 ml. of the above
Medicinal methylene blue Azure 1 0.8 gm

Azure 1 (Azure B) 0.5 gm

For “Solution B”

to the remaining 500 ml. add
Eosin, yellowish, water soluble 1.0 gm

To strain :•/,*, l ■ • . •

Allow rather thin thick films made with three
or fopi- small drops .of bipod to dry until

drop no longer shines (drying may be has-
tened by gentle heating)

Dip 1-2 seconds in Solution A
Wash in distilled water or rain water
Dip 1-2 seconds in Solution B
Wash as above, drain, dry thoroughly and
examine.

For those who have had little or no prac-
tice in the recognition of malaria parasites
in thick blood films, a somewhat slower
method of staining is the one of choice.*
It is briefly, as follows:

Prepare even thick blood films

Allow to dry flat until no longer shiny

Dip for one second in dilute methylene
blue solution

Wash gently in distilled water or rain
water

Stain face down 5-10 min. in solution of
Giemsa stain prepared by adding one
drop of stain to 1 c.c. of buffered water.

Wash, drain, dry thoroughly and examine.

SUMMARY

1. That malaria will be introduced into
the United States as a result of the war is
already a foregone conclusion.

2. A number of case histories of malaria
with bizarre manifestations are briefly
mentioned.

3. A warning to physicians of the gravity
of falciparum infections is given.

4. A rapid method for the staining of
thick blood films is given and a further
method for general use is recommended.

REFERENCES

1. Boyd, M. F., Stratman-Thomas, W. K., and Kitchen,
S. F. : Technique for the use of malaria in paresis, Am.
J. Trop. Med., 16 ; 324, 1936.

2. Boyd, M. F., and Kitchen, S. F. : Comparative sus-
ceptibility of malaria parasites, ibid., 16 ; 70, 1936.

3. Soper, F. L., and Wilson, D. B. : Anophels gambiae
in Brazil 1930 to 1940., Rockefeller Foundation, N. Y. C.,
1943.

4. Most, H., and Meleney, H. E. : Falciparum malaria :
the importance of early diagnosis and adequate treat-
ment, J. A. M. A., 124 :71, 1944.

5. Field, J. W. : Further note on a method of staining
malarial parasites in thick blood films, Trans. Roy. Soc.
Trop. Med. & Hyg., 35 ; 35, 1941.

*A supply of the necessary materials for this method
will be made available at cost to all members of the
Orleans Parish Medical Society who apply to Mr. A. J.
Kuhlman at the office of the Secretary of the Society.
Directions for use and a specimen stained slide or normal
blood will be included with the staining materials.

D’ Antoni — Symposium — Tropical Medicine

101

THE DYSENTERIES

JOSEPH S. D’ANTONI, M. D.

New Orleans

INTRODUCTION

The statement so frequently heard today
that the present diseases of Africa and of
the islands of the Pacific will be the future
diseases of the remotest villages of Amer-
ica is exaggerated, as all generalizations
tend to be. It is nonetheless based on literal
truth. It is not inconceivable that within
the next few years every physician will be-
gin his investigation on every new patient
with an inquiry as to whether he — or she
— served in the armed forces of the United
States, and if so, where. For today Amer-
icans from all parts of the country have
gone to the four corners of the earth, and
the diseases which they may contract there
and which they may bring home with them
concern the whole medical profession, par-
ticularly those of us whose primary interest
is tropical medicine.

The possible introduction into this coun-
try of diseases which produce dysentery has
an individual as well as an epidemiologic
aspect. From the individual standpoint, the
question immediately arises as to whether
or not a person who is suffering from, or
who has ever suffered from dysentery is
likely to suffer in the future as the result
of his disease. The answer naturally de-
pends in part upon how promptly the con-
dition has been diagnosed and how ade-
quately it has been treated. Yet even when
these criteria are met, the chances are that
the person who has once had one or another
of a certain group of dysenteric diseases
may be affected by their sequelae, in some
instances to the point of complete invalid-
ism. This is true for two reasons: (1)

Some of the acute dysenteries are charac-
terized by a strong tendency towards recur-
rence; (2) dysentery never develops until
some degree of intestinal ulceration has
occurred. Intestinal ulceration of any de-
gree is necessarily followed by scarring of
some degree, which leads, at least in some
instances, to recurrent or even permanent
disability.

From the epidemiologic standpoint, the
questions of the importation of the more
common dysenteries as the result of the war
is in one sense not important. The dysen-
teric diseases which soldiers are most like-
ly to contract, and which therefore are most
likely to be imported, are already prevalent
in this country, and in no small numbers,
at that. We are a supposedly hygienic na-
tion. We have a vast store of information
on, and we have applied our knowledge of,
such subjects as sewage disposal, water
purification, pasteurization of milk, insect
control, and the non-use of human feces for
fertilization. Yet in spite of this knowl-
edge we have not yet eliminated the two
most common dysenteric diseases, bacillary
dysentery and amebic dysentery, which are
the diseases soldiers are most likely to con-
tract and to import.

It is not true, however, to say that the
introduction of these diseases is of no im-
portance at all. The types which are preva-
lent in the Tropics are possibly more viru-
lent than those now prevalent in this coun-
try, and it is reasonable to postulate that the
introduction of even a small number of cases
of virulent dysentery might mean, in time,
the dissemination through the country of
the same virulent types. How to prevent
this catastrophe is not, of course, the sub-
ject of this paper, which is concerned only
with the possibility or the probability of
their importation.

GENERAL CONSIDERATIONS

Before proceeding to a discussion of spe-
cial varieties of dysentery, certain general
considerations should be mentioned. One
of them is the matter of nomenclature.
Dysentery is a term which is rather gener-
ally misused. In the first place, and con-
trary to ordinary usage, dysentery is really
the symptom of a disease and not a disease
in itself. In the second place, and again
contrary to ordinary usage, dysentery and
diarrhea are not synonymous terms, and it
is unfortunate that they are so often used
as if they were. Some writers prefer to
discard the term dysentery altogether and
to describe all liquid stools as diarrheic,

102

D’ Antoni — Symposium — Tropical Medicine

differentiating them on the basis of whether
or not they contain blood, but it seems more
reasonable to retain both terms and to use
them in their proper significance.

Diarrheic and dysenteric stools are sim-
ilar in that both are abnormally frequent,
both are unformed, and both contain mucus,
but there the resemblances end. A dysen-
teric stool contains pus and blood in large
amounts, while a diarrheic stool contains
blood infrequently and pus even more in-
frequently. The chief distinction between
them, however, is that a diarrheic stool is
composed chiefly of fecal matter, very little
of which appears in the dysenteric stool,
whereas the dysenteric stool, as the result
of intestinal ulceration, contains cellular de-
bris, which is always lacking in the diar-
rheic stool, because intestinal ulceration is
not a feature of diarrheic diseases.

In contrast to the numerous diseases in
which diarrhea may be a symptom, the dis-
eases which produce dysentery are limited,
even in the Tropics, where they are more
frequent than anywhere else in the world.
Their incidence varies according to the
country under discussion, but in general
the four most common dysenteric diseases
are bacillary dysentery, amebic dysentery,
balantidial dysentery, and schistosomal (bil-
harzial) dysentery.

Of less importance, because they are not
infectious, or because their incidence in this
country is already high, or because they are
not usually associated with dysentery, are
lymphopathia venereum (lymphogranuloma
inguinale), non-specific ulcerative colitis,
salmonellosis, and brucellosis. In four
other diseases, malaria, leishmaniasis (kala
azar), carcinoma of the intestines, and
tuberculosis, dysentery is observed only in
the late or terminal stages. Isospora ho-
minis, Giardia lamblia, Trichomoivas ho-
minis, and Chilomastix mesnili, although
mentioned by a few authorities as respon-
sible for dysenteric manifestations, either
do not invade the intestinal mucosa or do
not remain in the wall for a sufficiently
long period to cause pathologic changes. In
my own opinion the possibility of dysenter-
ies of such origins is remote.

Although cholera produces diarrheic
rather than dysenteric symptoms, it should
at least be mentioned in a discussion of the
dysenteries because it is a serious epidemio-
logic problem in the Tropics. The chances
of its importation into this country are not
great, since all soldiers in cholera areas
have been vaccinated against it, and vac-
cination is generally effective, as are quar-
antine regulations. The vibrio is not usu-
ally carried by humans for very long periods
of time, and its importation depends upon
only three possibilities: (1) That mild in-
fections might develop in vaccinated sub-
jects; (2) that vaccinated subjects, while
themselves not presenting clinical diseases,
might become carriers of the organism; (3)
that the disease might be brought in by
persons ill with it, or persons in the incu-
bation period, who are travelling by air.

Schistosomiasis, leishmaniasis ( k a 1 a -
azar), and malaria will be discussed else-
where in this symposium and will therefore
be mentioned only incidentally or disre-
garded completely in this paper.

BAC ILLARY I > Y SENTER Y

The distribution of Shigella, the etiologic
agent of bacillary dysentery, is world-wide,
although species and types vary greatly in
virulence in different parts of the world.
The most virulent type now known, Shigella
dysenteriae (Shiga) , already exists in Japan
and other parts of the Far East, and is like-
ly to spread extensively by the exigencies
of war. It is therefore reasonable to as-
sume that as conquered territories are re-
conquered by our armies, outbreaks of these
virulent types of dysentery will occur and
will increase as the conquering armies draw
closer and closer to the home islands of Ja-
pan.

Other problems must be faced in addition
to those inherent in the acute disease. If
certain observations in this field can be ac-
cepted, a small proportion of all patients
with bacillary dysentery in later life de-
velop non-specific ulcerative colitis, and the
incidence of this disease may therefore be
higher in the near future than we ever con-
ceived that it could be, as a result of the
presently increased incidence of acute bacil-

D ’ Anto N I — S ymp osium — Tropical Medicine

103

lary dysentery in the armed forces. This,
however, will be a matter affecting only
the individual victim and not one of impor-
tance from the standpoint of dissemination.

True explosive outbreaks of Shigella in-
fection are relatively rare in general popu-
lation groups. These organisms, however,
frequently spread widely, although slowly,
through such groups when they are intro-
duced, and high prevalence ratios are com-
monly encountered. The chances of spread
are particularly great whenever sanitary
conditions are poor or overcrowding of the
population is present.

Because bacillary dysentery is of both in-
dividual and epidemiologic significance, the
therapy of the disease warrants brief men-
tion, even in a paper of these limits. The
introduction of sulfaguanidine and of suc-
cinyl sulfathiazole has not solved the prob-
lem, as once seemed likely. Both drugs re-
lieve symptoms, it is true, and both cause
Shigella to disappear from the stools, but
neither of these immediate results in an
adequate long term criterion of cure, from
the standpoint of recurrence of the infec-
tion, reinfection, or the prevention of se-
quelae. My own experience makes me ques-
tion the effectiveness of these drugs in
chronic bacillary dysentery, in which, on
the basis of clinical improvement and sig-
moidoscopic evidence of improvement in the
lesions of the intestinal mucosa, I secured
good results in only three of 40 cases. It
is interesting to observe that recent reports
concerning them are considerably more
guarded than were earlier reports.

On the basis, again, of the immediate
criteria previously mentioned, sulfadiazine
seems considerably more promising than
either sulfaguanidine or succinyl sulfathia-
zole. Recent data indicate that it causes
Shigella to disappear from the stools more
rapidly than either drug, and that, using the
criteria of symptomatic improvement and
improvement in the state of the bowel wall,
it is also more effective in the chronic type
of bacillary dysentery. Unfortunately, sul-
fadiazine must be administered cautiously
in the Tropics, where it would have its
widest field of usefulness, because of the

risk of kidney complications, which is en-
hanced as the result of the dehydration al-
most inevitable in warm climates.

AMEBIC DYSENTERY

The intestinal protoza Endamoeba his-
tolytica, like the Shigella group, is of world-
wide distribution. Wherever it is looked for
it is found. In temperate climates the in-
cidence of amebic dysentery is not high, the
disease in these regions commonly occurring
in the form of amebiasis. In the Tropics
amebiasis is very common and is frequently
the chief disease with dysenteric manifesta-
tions. Three factors are probably respon-
sible: the low level of sanitation, the gen-
erally poor nutrition of the population, and
unknown climatic factors.

The inability of Endamoeba histolytica to
multiply, which reduces its epidemic po-
tentialities, has already been (mentionied.
From the standpoint of the individual, how-
ever, amebic dysentery presents more seri-
ous problems than does bacillary dysentery.
Spontaneous cures, with permanent disap-
pearance of the parasite, occur in the great
majority of all cases of bacillary dysentery,
whereas in amebic dysentery no such im-
munity develops and the organism continues
to inhabit the intestinal tract. The host
thus becomes a cyst-passer and presents
what is called asymptomatic amebiasis.
Actually, the disease is frequently npt
asymptomatic, for after therapy the patient
often realizes that symptoms were present
of which he was not cognizant until he was
rid of them.

Still another possibility must be consid-
ered. My own experience is that when pa-
tients with so-called asymptomatic ame-
biasis lost their resistance, as the result of
such factors as exposure, overwork and ex-
haustion, they are prone to develop acute
amebic dysentery. The acute phase of the
disease may lead, in turn, to such complica-
tions and sequelae as amebic hepatitis, ame-
bic liver abscess, perforation of the intes-
tine, ameboma, amebiasis cutis, amebic ab-
scesses of the brain, lungs or kidneys, and
possibly, in later life, carcinoma of the in-
testine.

For these various reasons the therapy of

104

D’ Antoni — Symposium — Tropical Medicine

amebic dysentery and of amebiasis, like the
therapy of bacillary dysentery, warrants
brief mention. All patients who harbor the
parasite, whether or not they present symp-
toms, should be treated. Emetine hydro-
chloride is probably more widely used than
any other amebicide, and the general
opinion is that it is a highly effective drug.
The introduction of more refined methods
of diagnosis, and particularly of the zinc
sulphate technic, has thrown considerable
doubt upon this belief. It is true that the
drug is highly effective in relieving the
acute symptoms of amebic dysentery, that
it is the only drug effective in the therapy
of ameboma (amebic granuloma) and in the
various extra-intestinal amebiases just enu-
merated. But its curative effectiveness is
probably less than 50 per cent in the dysen-
teric variety of amebiasis and less than 30
per cent in the non-dysenteric variety.

My own opinion, based on a personal ex-
perience of 126 cases of amebiasis treated
with diodoquin, including 20 cases with
dysenteric manifestations, is that this is the
drug of choice in this disease. It was effec-
tive in 99 per cent of patients in this series,
92 per cent of whom were cured by a single
course of treatment.

In connection with amebiasis, a personal
observation might be mentioned, since, so
far as I know, it has not been emphasized
by any other worker in this field. It is that
in a large percentage of cases symptoms
persist for a time even after the infection
is cured. Because this fact is not generally
comprehended, cases such as the following
can occur :

Early in 1941 a patient was referred to
me from the central part of the United
States, with a diagnosis of refractive ame-
biasis. She had contracted the disease in
the Chicago epidemic of 1933, and tropho-
zoites of Endamoeba histolytica, had been
found in her stools at the time. Dysenteric
symptoms recurred after the first course of
treatment, and a second course of therapy
was at once instituted. The cycle of symp-
toms and treatment continued over the in-
tervening seven-year period until some
eighty full courses of therapy, including

every known amebicide had been adminis-
tered. Inquiry revealed that only the single
stool examination had been made, immedi-
ately after the infection had been contract-
ed, in 1933. Repeated stool examinations
in 1941 were negative, as might have been
expected : The concentrated therapeutic reg-
imen had destroyed all the organisms, prob-
ably many years ago, and my only wonder
is that it did not also destroy the patient,
who was found to have brucellosis, which
readily explained the persistence of the
dysenteric stools.

A diagram (p. 105) may clarify my point.
A particular symptom, diarrhea (though
any other symptom could be similarly pre-
sented), is depicted as occurring in weekly
attacks for 10 weeks, in the form of eight
to 10 diarrheic stools daily. Within two or
three days after the institution of amebici-
dal therapy symptoms disappear, and they
remain absent as long as therapy is con-
tinued. This practically always occurs, re-
gardless of whether the amebicide is an or-
ganic compound, an iodine preparation, or
an arsenical.

When therapy is discontinued, symptoms
apparently due to amebiasis are likely to re-
appear after varying periods of time, and
repeated attacks of diarrhea may again oc-
cur, though they diminish in severity with
each recurrence. Regardless of the recur-
rent symptoms, amebicidal therapy should
not be re-instituted unless and until or-
ganisms are again found in the stools, which
should be examined at routine intervals as
well as during exacerbations.

The physician who is not familiar with
the sequence of events just outlined, and
particularly with the tendency of symptoms
to recur, though with diminished severity,
for some time after parasites disappear
from the stools, is likely to re-institute ame-
bicidal therapy with each attack. As a re-
sult, as in the case described, the patient is
likely to be treated beyond his needs for
amebiasis, and whatever associated condi-
tion he may have is likely to be neglected.

BALANTIDIAL DYSENTERY

The parasite of balantidial dysentery,
Balantidium coli, is a common intestinal

D’ Antoni — Symposium— Tropical Medicine

105'

Theoreticail Representation
of Incidence of Symptoms in Amebiasis

BEFORE THERAPY DURING THERAPY
'Periods Subsidence
0/o of Symptoms of Symptoms

aftertherapy

■Recurrence
of Symptoms

ciliate of the pig and the monkey and is
world-wide in its distribution, though it is
rare in man except in certain tropical coun-
tries. It is classified as a pathogenic para-
site, and usually, when it penetrates the in-
testinal mucosa, the lesions and the result-
ant symptoms produce the general picture
of amebic dysentery. It may, however, live
in the human bowel without producing defi-
nite symptoms, though cysts are passed in
the stools, and it may penetrate the mucosa
without causing necrosis and ulceration.
Although spontaneous cure occasionally oc-
curs, cure by specific therapy is not readily
achieved, and the disease may prove fatal
in debilitated subjects, which makes it of
individual importance.

Since the incidence of Balantidium coli is
so high in hogs in America, while at the
same time it is so low in human subjects,
some factor as yet unknown probably plays
a part in the possibility of individual infec-
tion. Until this factor is understood, it is
impossible to say whether the introduction

of a few cyst-carriers into the country is
likely to cause any special problems after
the war.

THE DESS COMMON DYSENTERIES

Lymphopathia Venereum ( Lymphogran-
uloma Inguinale) : Whether or not this dis-
ease is likely to be imported into the United
States after the war can best be discussed
by those concerned with venereal disease
control, a part of which problem it is. Gen-
eral statements are difficult to make, since
the infection has been recognized only in
recent years. It is therefore scarcely fair
to say that the increasingly large number of
cases now being diagnosed represent a true
increase in incidence.

Two complications of lymphogranuloma
inguinale, ulcerative colitis and rectal stric-
ture, may give rise to typically dysenteric
stools, which may persist for months or
years. At the present time these complica-
tions are infrequent. In the last two years,
however, I have myself seen three or four
times as many rectal strictures of this origin

106

D’ Antoni — Symposium — Tropical Medicine

as I saw in the preceding six years, a fact
which I regard as significant, though I
have no explanation for it. Lymphogranu-
loma inguinale also seems to be an increas-
ingly frequent cause of nonspecific ulcera-
tive colitis, though again the statement must
be made with reservations : It is quite

possible that it was an equally frequent un-
recognized cause in the past.

For the present, lymphogranuloma in-
guinale is of importance to the individual
rather than to the general population. A
large increase in its incidence would be
necessary to make it otherwise. On the
other hand, it is fair to say that if the dis-
ease becomes more frequent, there will un-
doubtedly be an increase in both ulcerative
colitis and rectal stricture as a result, and
an increase, in turn, in dysentery of this
origin.

Nonspecific Ulcerative Colitis : Although
all dysenteries actually are forms of ulcera-
tive colitis, since dysentery does not exist
without intestinal ulceration, the term non-
specific ulcerative colitis is reserved for
those types the etiology of which is unrecog-
nized. The incidence of the disease ob-
viously depends upon the diagnostic ability
of the profession : The poorer the diagnosis
from the standpoint of etiology, the higher
will be the incidence. As just pointed out,
recent increases in our knowledge of lymph-
ogranuloma inguinale have removed a cer-
tain number of cases from this classifica-
tion, and if the theory can be accepted that
80 or 90 per cent of the cases previously re-
garded as nonspecific ulcerative colitis are
really instances of food allergy, some of the
remaining cases in the group would also be
removed.

Ulcerative colitis is of both individual and
general importance. If diagnostic methods
have failed and appropriate treatment is
not applied, the prognosis for the individual
is correspondingly poor. From the epi-
demiologic standpoint it may be postulated
that some individuals with this disease are
likely to harbor virulent strains of para-
sites, and that the longer their disease re-
mains undiagnosed and untreated, the

greater is the probability of its dissemina-
tion.

Salmonella Dysentery : All of the com-

monly described varieties of Salmonella
have been found in this country, and in rela-
tively the same proportions as in other areas
of the world. Only a few special studies,
however, have been carried out on dysen-
teric disorders caused by this infection.
Some observers have reported cases of
dysentery due to these organisms in the
Tropics as well as in other areas. The inci-
dence in the New Orleans area, according
to James Watt (personal communication),
who is now studying the problem, seems un-
usually high for the United States.

Although it is of course possible that cer-
tain strains of Salmonella tend to produce
the dysenteric syndrome more frequently
than others, there is no real evidence to con-
firm such a supposition. Since, therefore,
all common types of Salmonella are found in
the United States at present, the likelihood
of importation of more virulent (dysen-
terogenic) strains is extremely remote.

Brucellosis Dysentery : Since Brucella in-
fection is transmitted by infected cattle,
and only occasionally, if at all, by man, bru-
cellosis is not an epidemiologic problem,
though it may show an increased incidence
after the war, as the result of the careless
and unauthorized drinking of infected milk
by soldiers. The incidence of the disease is
high in tropical countries, particularly the
variety due to Brucella melitensis, though a
dysenteric phase is unusual. In fact, one
experienced observer, Mr. Ruiz Castaneda
(personal communication), over a long
period of time, saw only one case with dy-
senteric manifestations.

Our knowledge of brucellosis in this
country is still not accurate, but the abortus
variety is unquestionably the most frequent.
In the last five years I have personally ob-
served nine cases of Brucella abortus infec-
tion with dysenteric symptoms, in addition
to the case already described in this paper
as treated for amebiasis. Two other cases
were also diagnosed as amebiasis, two as
chronic bacillary dysentery, and the remain-
ing five as nonspecific ulcerative colitis.

D ’ A N TONI — Symp osium — Tropica l Medicine

107

In all 10 cases diagnosis was made by con-
sistently high agglutinations, especially
during exacerbations, by positive skin tests,
or by a positive opsonocytophagic index ; at
least two of these tests were positive in
every case. All 10 patients improved symp-
tomatically on vaccine therapy.

Unusual ( Terminal ) Dysenteries : Throm-
bosis of the capillaries of the colon occurs
frequently in falciparum malaria, and
diarrhea is a not infrequent complication of
the disease, but secondary infection of the
thrombosed areas is unusual, ulceration, as
a result, does not often occur, and the inci-
dence of dysenteric manifestations is cor-
responding small. When they are present,
they occur late, and the prognosis, in the
absence of prompt and adequate treatment,
is always poor. Chronic dysentery is not
the rule in patients who recover.

The incidence of malarial dysentery in
this country after the war depends upon the
possibility of the introduction of tropical or
virulent malaria, which is discussed in an-
other paper of this symposium. Naturally,
the higher the incidence of this type of ma-
laria, the higher will be the incidence of ma-
larial dysentery, though at the most it will
remain small.

Although the submucosa and even the mu-
cosa of the intestine in kala-azar are infil-
trated with numerous macrophages filled
with Leishmania organisms, ulceration is
unusual except in the terminal stages, and
dysentery therefore does not occur in more
than a small proportion of all cases. The
rural incidence of kala-azar dysentery in
endemic areas is estimated at 10 per cent
and the urban at 1 per cent, differences in
sanitary practices explaining the discrep-
ancy. The explanation of dysentery is not
clear, though some authors regard it as an
intercurrent intestinal infection, such as
amebic or bacillary dysentery. Since the
chances of importation of a large number
of cases of kala-azar are remote, the likeli-
hood that dysentery of this origin will be of
importance in the United States after the
war is relatively small.

That the incidence of carcinoma of the
intestine is increasing is well known. If,

however, the concept should be established
that the end-result of acute, and more par-
ticularly of chronic, dysenteries may be the
development of malignant disease, this in-
crease would be of great importance to the
individual. It would mean, furthermore,
that in the next two decades we may antici-
pate a rapid increase in the general inci-
dence of intestinal malignancy, as the result
of the high incidence of acute and chronic
dysenteries among men in the armed forces.

Dysentery due to tuberculosis is extreme-
ly unusual and the etiology is clearcut, since
it is usually associated with demonstrable
pulmonary lesions. This was true in all
three cases which I have personally ob-
served.

SUMMARY

1. Because the armed forces of the
United States are fighting today in every
part of the world, the possibility exists that
the diseases of every part of the world may
after the war be introduced into every part
of the country.

2. This possibility must be considered
from both the individual and the epidemio-
logic standpoint.

3. The diseases which produce dysen-
tery (in contrast to those which produce
diarrhea) are limited in number, and the
two most important, bacillary dysentery
and amebic dysentery, are already prevalent
in the United States. The introduction of
more virulent types of bacillary dysentery
is, however, a possibility. Both diseases are
of individual significance, and bacillary
dysentery may assume epidemic propor-
tions.

4. Balantidial dysentery, though the
causative parasite has a high incidence in
certain animals, is apparently unusual in
man except in the Tropics.

5. The remaining dysenteries, such as
those associated with lymphogranuloma in-
guinale, nonspecific ulcerative colitis, sal-
monellosis and brucellosis, are not of gen-
eral significance. Dysentery is only occa-
sionally associated, usually in the terminal
stages, with such diseases as malaria, leish-
maniasis (kala-azar), and tuberculosis.

108

Napier — Symposium — Tropical Medicine

THE RICKETTSIA DISEASES; YEL-
LOW FEVER; DENGUE AND
SANDFLY FEVER

L. EVERARD NAPIER, M. D.

New Orleans

Since I have been assigned a compara-
tively negative role in this symposium I
shall make my contribution very brief.

My first assignment is rickettsia dis-
eases. There have been between thirty and
forty names given to the various rickettsia
infections of man. In many instances differ-
ent names have been given to the same dis-
ease, and in others the same name has been
given to more than one distinct disease en-
tity. Our knowledge of rickettsia disease
is in its earliest stages and there is natur-
ally a considerable amount of confusion ; in
the course of time no doubt the picture will
be clarified.

In table 1 nineteen names of rickettsia
infections are given. In several cases, even
here, more than one name is given to what
is obviously a single disease entity, and the
table is by no means complete, but perhaps
it contains all the more important rickettsia
diseases. They are arranged in six groups.
There are in a few instances some impor-
tant cross relationships between members

of different groups, but in each case, where
there is more than one representative in a
group, there is some strong epidemiologic,
etiologic, or clinical tie between the various
members of this group.

If you examine a map showing the world
distribution of some of the rickettsia in-
fections, you will notice that this war has
already taken American soldiers into many
places where these diseases are endemic.
What are the chances of soldiers on their
return bringing back some of these infec-
tions with them? It is possible that a sol-
dier might return to this country during the
incubation period and develop one of the
rickettsia diseases after he arrived; this is
possible but very unlikely in view of their
relatively short incubation periods. How-
ever, the important point is, would such an
incident be likely to introduce the infection
to this country? Examination of the table
will indicate that there is only one of these
diseases in which the reservoir of infection
is man, that is epidemic typhus. Epidemic
typhus has been introduced many times into
the United States and there have from time
to time been outbreaks of the disease here,
but none of importance within the last fifty
years, and in view of the fact that louse
infestation is very rare, it seems most un-

TABLE 1

RICKETTSIA DISEASES

Disease

Rickettsia

Epidemic typhus

R. prowazeki

Brill’s disease

R. prowazeki

Murine typhus

R. mooseri

Rocky Mountain spotted

fever;

R. rickettsi

Eastern and Western

Sao Paulo fever

R. braziliensis

Tobia fever

Fievre boutonneuse

R. conori

S. African tick fever

R. pi j peri

Tsutsugamushi disease or

>

Japanese river fever

R. orientalis

Scrub or rural typhus

or

Sumatra mite fever

/*•

nipponica

New Guinea mite typhus

Queensland coastal fever

J

Trench fever

R. quintana

Australian Q fever

R. burneti

American Q fever

R. burneti

(R. diaporica)

Vector

Reservoir

Louse

Man

—

(Man )

Flea: X. cheopis

Rats

cks : Dermacentor andersoni

W. Mammals or

and variabilis

Dermacentor

Amblyomma cayennense

Rodents

Ticks

Rodents

Dog tick: R. sanguineus

Rodents

Ticks

Rodents

Trombidial mites

Field

T. akamushi

rodents

T. deliense

Rats

?

Rodents

(T. minor)

Rodents

T. australiense

Rats

Louse

Louse

Ticks

Bandicoot

Dermacentor andersoni

?

Napier — Symposium — Tropical Medicine

109

likely that typhus would spread, even if it
were introduced.

In the same group as epidemic typhus,
Brill’s disease is listed. Now Brill’s disease
is a sporadic and very mild form of typhus
that has appeared in this country many
times. There is considerable evidence that
the rickettsia which causes it is identical
with that of epidemic typhus, and the ex-
planation given for these sporadic cases,
which have almost all been in emigres from
European countries where typhus occurs,
is that Brill’s disease is a late release phe-
nomenon in a person who has previously
suffered from epidemic typhus.

Epidemic typhus is essentially a war dis-
ease. An outbreak has followed every great
European war for as far back as historical
records on the subject are reliable. After
World War I there was an exceptionally se-
vere outbreak, in which in Russia alone
there were 4,000,000 cases in one year, and
in Serbia, as Yugoslavia was called in those
days, half the doctors in the country died
of the disease. This war is unlikely to prove
an exception ; in fact already last year there
was a severe outbreak in Egypt and North
Africa, and reports indicate that there is
an epidemic in Italy at present. True, all
soldiers are inoculated against typhus, but
the value of the vaccine has not been fully
proved and it is possible that it modifies
rather than prevents the infection. If Brill’s
disease is really a late relapse phenomenon
of epidemic typhus, it seems possible that
the future may bring forth a large num-
ber of such cases in soldiers returning from
Europe.

Further, an incident has been reported
from Ireland in which a box which con-
tained clothes that had belonged to a typhus-
infected family was incriminated as the
cause of a small outbreak of epidemic ty-
phus. It is thought that the infection
originated from infected louse feces which
had been shut up in the box for many years.
This is not impossible, as rickettsiae remain
viable for a very long time in the dry state,
and, if this is true, it opens up great pos-
sibilities for spora'dic cases in the post-war
years. No doubt precautions will be taken

to sterilize the soldiers’ clothes, but such
things as souvenirs may harbor the infec-
tion.

In the case of other rickettsia diseases,
man is not known to harbor the infection
for any length of time, nor is he likely to
bring either the vectors or the reservoir
hosts back with him. Furthermore, at least
three of the groups have other representa-
tives in this country already. One such dis-
ease is murine typhus; this was a rare dis-
ease in this country 25 years ago, but dur-
ing the last two decades it has shown a
progressive increase, and it appears to be
extending its range. The two initial foci,
one on the Mexican border and the others
on the Southern and Eastern seaboards are
tending to meet. This will be more evident
when the data for the last few years are
analyzed. The Southern states are prima-
rily involved, but it has been reported from
other states.

Rocky Mountain spotted fever, which is
no longer confined to the Rocky Mountain
states but has occurred in nearly every state
in the union outside of New England, is
another example. The distribution map, re-
cently prepared by Faust, appears to sug-
gest that this disease also is spreading. It
is by no means certain that this is really
the case, and it is possible that the map only
indicates a greater awareness and a higher
degree of diagnostic acumen on the part of
the medical profession.

Finally, there is that very interesting dis-
ease referred to as “Q fever,” which has
also been called “nine-mile fever.” At pres-
ent this is more of a medical curiosity than
a public health problem, but so was murine
typhus twenty-five years ago.

It is not likely that new strains of any
of these diseases will be brought in as a
direct or indirect result of the war, nor are
war conditions in any way likely to increase
their incidence to any serious extent, but
perhaps the revival of interest in tropical
medicine that this war has initiated, will
have as one of its results an increased inter-
est in rickettsia infections generally, so that
more attention will be paid to these tropical

110

Napier — Symposium — Tropical Medicine

— well, if not tropical, at least exotique —
diseases already prevalent in this country.

Rocky Mountain spotted fever is usually
a severe disease with a very characteristic
clinical picture that includes an intense
rash and it should be diagnosable clinically.
Murine typhus and Brill’s disease are mild-
er diseases in which the rash may be ab-
sent, but a doubtful diagnosis can be con-
firmed by the simple Weil-Felix reaction
with 0X19 antigen, in the second week of
the disease. The diagnosis of Q fever pre-
sents more difficulty. It usually takes the
form of a pneumonitis. The diagnosis can
also be confirmed serologically, though not
in this case by the Weil-Felix reaction.

YELLOW FEVER

Again, this is a disease which should not
be introduced as a direct result of the war,
provided there is no relaxation of preven-
tive measures. In the past, epidemics have
from time to time occurred in the United
States, but only one since the mode of trans-
mission of the disease was understood,
namely the New Orleans epidemic of 1905.

Most of the epidemics came and went be-
for the Stegomyia mosquito (Aedes aegyp-
ti) was known to be the vector. It must
therefore be apparent that climatic condi-
tions in the United States are unsuitable for
the disease to establish itself permanently
here.

For yellow fever to occur in epidemic
form, there are three essentials: (1) the
yellow fever virus; (2) the mosquito vector,
and (3) a susceptible population.

Now, if the virus can be excluded from a
country, or if the vector mosquitoes can be
eliminated or reduced to a non-effective
level, or if the population can be protected
by vaccination, then the disease will not
occur. The point of attack will depend en-
tirely on the circumstances.

As you probably know, epidemiologically
there are two types of yellow fever — the ur-
ban and the jungle types. In the former
the source of infection is man and the vector
is the Stegomyia mosquito ; and in the latter
the source is some jungle animal, as yet
unidentified, and there are twenty or more

mosquitoes that are capable of transmitting
the infection.

In table 2 are shown the methods of con-
trol adopted in four sets of circumstances.

TABLE Z

THE CONTROL OF YELLOW FEVER

The relative importance of different methods in
various circumstances

Endemic Non-endemic

Method

areas

C

o'

95

s

Jungle.

areas

« 8-
3 O
Q- 3
fD

o
c ET

3 3
ce 93
C cj.

Exclusion of

3 5

sv ^

p &

cr E3

the virus

,

L

++

+

Elimination of

the vector

+ +

—

+

+ +

Protection of man

by inoculation ..

+

++

—

—

It is quite obvious that in the endemic
areas one cannot exclude the virus; it is
already established there in the human pop-
ulation or in the jungle reservoir. In an
urban endemic center the main effort will
be directed towards the elimination of the
vector, but this would be quite impossible
in a jungle area. Thus, in a jungle area
we are left with inoculation of the whole
population as the only possible means of
prevention, and in Brazil and Colombia
several millions of people have in fact been
inoculated against yellow fever. This gives
maximum protection for about four years,
after which there is some evidence that im-
munity tends to decrease in certain persons.
Of course, inoculation will be of value
amongst a town population in an endemic
area, but it should not be looked upon as
the first and only line of defense as in the
jungle areas. Further, many people will
already be naturally protected by previous
experience of the disease.

The case of the non-endemic areas is very
different. Moreover, there are vast areas
in Asia where Stegomyia mosquitoes
abound. These are all potential endemic
areas, and, if the virus once established it-
self there, it would seem that nothing could
prevent a most disastrous outbreak. The
virus could arrive either in a person during
the incubation period, or during the first

Napier — Symposium — Tropical Medicine

111

three days of the disease, which might be
mild or even symptomless, or in any in-
fected mosquito. The measures that are
taken in India, which is the western gate-
way to Asia, are aimed at preventing its
slipping through in either. Everyone arriv-
ing in India from a yellow fever area must
have been inoculated 14 days before he (or
she) arrived in that yellow fever area, or
he is isolated until nine days have elapsed
since he left the last yellow fever country,
whether he is a private, a field marshal, or
a cabinet minister. As well as having to
pass through anti-amaryl aerodromes en
route, where preventive measures are taken,
all airplanes are compelled to arrive at one
airport in India and on arrival they are
thoroughly de-insectized before anyone is
allowed to get out. That is to say, the main
aim is preventing the virus from entering
the country, and, while anti-mosquito meas-
ures are also taken, especially near aero-
dromes, it would be impossible to keep the
Stegomyia population of this whole conti-
nent down to a safe level, just as it would
be impracticable to inoculate its thousand
million odd inhabitants, so that these two
measures are relegated to positions of sec-
ondary importance.

A map which shows that the main direct
air routes from the United States to India
pass through or near the worst yellow fever
areas in the world also shows the proximity
of the South American yellow fever to this
country, but it does not by any means show
all the air links.

The position in the United States is dif-
ferent: We are very near the endemic foci
in South America, and therefore in some
ways the danger would appear to be greater,
but past experience has shown that the cli-
mate here is inimical to permanent yellow
fever endemicity, though epidemics may oc-
cur.

With the endemic areas so near and with
so many ports of entry, it would be impos-
sible to be certain that no infected man or
mosquito ever arrived in the country, so
that the main aim has been to keep the
Stegomyia mosquitoes at such a low level —
a 2 per cent Aedes aegypti index is usually

considered safe — that if by any chance the
virus did arrive again, the disease would not
spread. Of course, very elaborate precau-
tions are taken at all ports and air-ports to
prevent infected mosquitoes arriving, but
the strict regulations regarding inoculation
that are applied in India are not applied
here, and, although I believe the local health
authorities are notified when an uninocu-
lated person arrives from a yellow fever
country within the incubation period, he is
not isolated.

The increased air traffic resulting from
the war of course increases the danger of
a temporary return of yellow fever to the
United States. To meet this danger addi-
tional precautions have been taken in many
places, though I am told that the Aedes
aegypti index of New Orleans rose far
above the safe level last fall, which is ob-
viously a dangerous situation. All the army
personnel are inoculated against yellow fe-
fevr, but to extend this precaution to the
civil population would be too drastic a meas^)
ure in the circumstances.

DENGUE AND SANDFLY

These two diseases are related to one an-
other in that they are both short fevers
caused by filtrable viruses and are trans-
mitted from man to man by insects. The
differences are shown in table 3.

TABLE 3
Dengue

1. Virus present for first three days of fever.

2. Transmitted by Aedes aegypti.

3. Eight days development in mosquito.

4. Mainly tropical.

5. Fever lasts five to seven days usually, some-

times less.

Secondary rise of temperature occurs in 25 to
80 per cent of cases in different epidemics.

6. Primary rash occasionally; secondary rash all

over the body, in most epidemics.

7. Immunity is variable and tends to be short.

Sandfly fever

1. Virus present day before fever and for the

first two days of onset.

2. Transmitted by Phlebotonuis papatasii.

3. Seven days development in sandfly.

4. Mainly sub-tropical.

5. Fever lasts three to five days, usually, some

times longer.

Secondary rise of temperature rare.

112

Sene kj IE — Symposium — Tropical Medicine

6. Primary rash rare.

7. Immunity is usually complete.

Dengue is today not unknown here, al-
though epidemics have occurred previously.
Increase in the traffic might easily lead to
the re-importation of the disease from South
and Central America, and, if the Stego-
myias, of New Orleans, for example, are
again allowed to get out of hand, an epi-
demic might well occur and cost this coun-
try’s war plants some hundreds of thousand
of man-days. Sandfly fever, on the other
hand, is not likely to occur. There are few
phlebotomi in this country and those that
are present do not feed on man.

I have drawn as gloomy a picture as I
can, and, while I do not believe that I have
exaggerated the possibilities, I do not think
that any of the diseases I have discussed,
with the possible exceptions of yellow fever
and dengue, are really very likely to provide
either war-time or post-war problems to
worry the medical profession, as undoubted-
ly will some of the diseases discussed by my
colleagues.

o

HEMOFLAGELLATE INFECTIONS

HARRY A. SENEKJIE, M. D.

New Orleans

INTRODUCTION

From the protozoologic and pathologic
points of view, it is very easy to trace the
evolution of Trypanosoma and Leishmania
diseases of man.

The most primitive in the evolutionary
scale is a group of diseases caused by leish-
manias, since the parasite occurs in the
leishmania stage in the reticulo-endothelial
cells of the vertebrate host and in the flagel-
late leptomonas stage in the sandfly and in
culture. Therefore the primary pathology
is one of reticulo-endotheliosis, while the
parenchyma suffers only accidental and
secondary changes.

The second group of diseases is African
trypanosomiasis where the parasite lives
and multiplies extracellularly in the blood
and tissue fluids in the flagellate trypano-
some stage, thus giving rise to primary
pathology in the parenchyma of the viscera,

mainly the lymphatic and central nervous
system. Mesenchymal reaction is second-
ary. In the invertebrate host, the tsetse
fly, and in culture media the parasite is in
the flagellate crithidia and trypanosome
stages.

The third group, which is the highest in
the evolutionary scale, is American trypano-
somiasis, in which the parasite multiplies
in the leishmania stage in the parenchyma
and mesenchyma cells of the various organs,
while the blood forms are flagellate try-
panosomes, and leptomonas and crithidia
stages are transitory. The pathology in-
cludes both a reticulo-endotheliosis and pa-
renchymal lesions. In the insect vector,
the triatomid bug, and in culture the cri-
thidia and trypanosome forms are pro-
duced. Thus, in this disease, the parasite
goes through a complete cycle — leishmania,
leptomonas, crithidia and trypanosome.

I. RETICULO-ENDOTHELIOSIS

1. Kala-azar

Visceral leishmaniasis or kala-azar which
is produced by Leismania donovani, has a
very extensive distribution. The Chinese
type occurs mainly among children who are
above five years and the dog is an important
reservoir host. The Indian type occurs
among adults and children, but no reser-
voir host has been discovered. Infantile
kala-azar (the Mediterranean type) occurs
among younger children and dogs. The
Sudanese type occurs among all age
groups. This is also the case in Argentina
and Brazil, where the dog and cat are reser-
voir hosts.

Clinical Course: Kala-azar is a chronic
disease which has an incubation period of
two to three months or more, and is char-
acterized by the gradual onset of fever re-
curring at irregular intervals, typically with
a double daily rise of temperature every 24
hours. Progressively there is spleno-hepa-
tomegaly, hypochromic microcytic anemia,
leukopenia with monocytosis, edema of the
skin, loss of weight, emasculation, diarrhea
or dysentery, cachexia, granulopenia, dusky
pigmentation of the skin, stunting of
growth and intelligence, hemic murmur,
hypoproteinemia with elevation of the se-

Se ne k j ie — 5 ymp osium — Tropical Me dicine

113

rum euglobulin level, a clean tongue, a good
appetite and no jaundice, and death is usu-
ally due to an intercurrent infection.

Although any fever with or without
splenomegaly must be considered in the dif-
ferential diagnosis, the most important dis-
eases which must be excluded are malaria,
typhoid fever, Egyptian splenomegaly,
schistosomiasis, Banti’s syndrome and
syphilis.

Laboratory Diagnosis : During the febrile
stage thin and thick blood films stained with
Wright’s or Giemsa’s stain may reveal the
parasites in the mononuclear cells, while
cultivation on the N.N.N. medium, and in-
oculation of hamsters are valuable supple-
mentary tests. Examination of sternal bone
marrow and splenic pulp is of particular
value in chronic cases. The Napier aldehyde
test, antimony test and Sia’s precipitation
test are relatively pathognomonic.

Treatment : The specific drug is anti-
mony. Trivalent antimony salts, 2 per cent
freshly prepared solution of tartar emetic
or sodium antimony tartrate, injected intra-
venously, beginning with 2 c.c. and grad-
ually increasing the dose to 5 c.c. Injections
are given twice a week for a period of two
to three months.

Fuadin or neoantimosan is given intra-
muscularly with an initial dose of 1.5 c.c.
and gradually increased to 5 c. c. Fifteen
injections are necessary.

Of the pentavalent salts, neotibosan is
the most efficient. It is given intravenous-
ly with an initial does of 0.1 gram, which
is gradually increased to 0.3 gram until
2.7 to 4 grams are given. Anthiomaline,
diramine, stibamine glucoside, solustibosan
and urea stibamine are also used.

Toxic symptoms due to the administra-
tion of antimony are cough, metallic taste
in the mouth, vomiting, giddiness, delirium,
rise and fall of temperature, cramps in the
muscles of the calf, rapid pulse, colic, head-
ache, arthritic pains and jaundice.

2. Mucocutaneous South American Leish-
maniasis, Utaor Espundia

This is a chronic disease which is found
in Latin America and is caused by Leish-

mania brasilensis. The known reservoir
host are the dog and the agouti.

Clinical course: (a) Cutaneous stage. At
the site where the sandfly introduces the
parasite on the exposed parts of the body
a macule appears, which becomes a papule,
ulcerates, and on healing leaves a scar. This
stage lasts for one to two years.

(b) Mucocutaneous or metastic stage :
This develops around the nose or mouth
after healing of the primary lesion. It is
a destructive and ulcerative process extend-
ing posteriorly and destroying the soft parts
of the nose as low as the pharynx and tra-
chea, thus interfering with respiration and
nutrition. Contraction of the tissues re-
sults in disfigurement. At times there is
fever, anemia and pain in the affected
parts. Complications are pneumonia and
septicemia.

Laboratory Diagnosis : Smears of the le-
sion show parasites in the mononuclear
cells. Culture on the N.N.N. medium, in-
oculation of the hamster and the Monte-
negro allergic skin test are also used.

Treatment : Antimony salts are specific.
(See above.)

3. Cutaneous Leishmaniasis, Oriental
sore, Aleppo, Delhi or Bagdad Boil

Clinical Course : This is a disease of the
skin which occurs in certain parts of Asia,
Africa and Europe, but is not co-endemic
with kala-azar. It is caused by Leishmania
tropica. Usually on the exposed parts of
the body, two to 12 months following the
introduction of the parasites by the sand-
fly, a macule appears, becoming a papule. ,
With trauma it ulcerates and finally heals
after nine to 12 months, leaving a disfigur-
ing scar. Clinically the lesion is usually
single, generalized, and abortive. Lym-
phatic, verrucous and lupus types have also
been observed.

Laboratory Diagnosis : Smears of the le-
sion show the parasites in the mononuclear
cells. Cultivation on the N.N.N., inocula-
tion of the hamster, agglutination and skin
tests are also used.

Treatment : For the preulcerative stage,
atabrine infiltration of the lesion is recom-

114

Senekjie — Symposium — Tropical Medicine

mended ; for the ulcerative stage, clean with
hydrogen peroxide and apply sulfapyridine
powder. In refractory cases systemic use of
antimony, local application of CO, snow,
berberine sulphate, or emetine hydrochlor-
ide may be needed.

Prophylaxis : Induce artificial boil by in-
jecting living leptomonas from bacterially
sterile cultures on the covered parts of the
body. Immunity follows the healing of the
lesion. Super-infection is possible, but re-
infection does not take place.

II. PRIMARY PARENCHYMAL, PATHOLOGY

1. African Trypanosomiasis

a. Gambian Fever : This is a chronic dis-
ease occurring in Africa between 15° N.
and 15° S. of the equator, mainly the west-
ern and central parts. It is characterized
by changes in the lymphatic and nervous
systems. The etiologic agent is Trypano-
soma gambiense.

Clinical Course : The incubation period
is two weeks to a few months. The glan-
dular stage begins with a trypanosome
chancre which develops at the site of the
bite of an infected tsetse fly, fever, erythe-
matous rashes, edema of the hands, feet,
eyes and joints, a generalized lymphadeno-
pathy especially marked in the posterior
triangle of the neck (Winterbottom’s sign),
and delayed reaction to pain (KerandeTs
sign) . Progressively the fever becomes very
irregular and the patient shows asthenia,
anemia, neutropenia with monocytosis,
weakness, eye complications, and erythema
nodosum. Death may result from intercur-
rent infection, but commonly it is followed
in two to seven years after the initial in-
fection by the cerebral or lethargic stage,
due to the invasion of the brain by the para-
sites. The symptoms in this stage are tre-
mors, headache, delusions, hysteria, mania,
apathy, dullness, difficulty in walking, for-
getfulness to masticate the food and loss of
the deep reflexes. Progressively the gait
is shuffling, the expression becomes vacant,
there are drooping and edema of the eyelids,
somnolence during the daytime and restless-
ness at night, paralysis, convulsions, rigid-
ity of the neck, retraction of the head, bed-

sores, salivation, lethargy, loss of sphinc-
teric control, hyperpyrexia, coma and death.
Differential diagnosis must be made from
malaria, kala- azar, pellagra, syphilis, lepro-
sy and beriberi.

Labora tory Diagnosis : The parasites can
be demonstrated in the blood by the thin
and thick blood methods, and in lymph pulp
and cerebrospinal fluid. The infection can
be transmitted to mice, rats and guinea
pigs.

Treatment : Tryparsamide, a pentavalent
arsenical, is given intravenously with an
initial dose of one gram and progressively
increased to 2 to 3 grams at weekly inter-
vals until a total dose of 24 to 80 grams has
been administered. One hundred per cent
cures may be expected if the nervous system
is not invaded, but only 17 to 50 per cent
cures if this stage has been reached. Bayer
205 (germanin) is also effective, and is
given in 1 gram doses intravenously 'at
weekly intervals for a total dose of 10
grams. Combined treatment is the most
effective.

Toxic symptoms which often occur dur-
ing the arsenical treatment are optic neuri-
tis, dermatitis, hepatitis, albuminuria, head-
ache, confusion, aphasia and coma.

b. Rhodesian Fever : This is a subacute
disease occurring in East Africa 10° to 14°
South of the equator, and is caused by Try-
panosoma rhodesiense. It has a much
shorter duration and graver prognosis in
man and experimental animals than Gam-
bian fever. There is no clean-cut distinc-
tion between the glandular and cerebral
stages, but there is a marked typanosome
chancre. The drug of choice is Bayer 205,
which gives only 50 per cent cures if the
central nervous system is not invaded, but
is fatal once this stage has been reached.

HI. RETICl'LO-ENDOTH ELIO SIS AND PARENCHYMAL
PATHOLOGY

American trypanosomiasis or Chagas’
disease

This is a chronic disease of man in Latin
America caused by Trypanosoma cruzi, but
the parasite has been found in triatomid
bugs and reservoir hosts in Texas, New
Mexico, Arizona and California.

F aust — Symposium — Tropical Medicine

115

Clinical Course : The incubation period
is one to two weeks. The acute form ob-
served in children has a slow onset of high
continued fever, with a slight morning drop,
unilateral or less commonly a bilateral
swelling of the eyelids and conjunctiva
(Romana’s sign) at the site of the bite of
the bug, a non-pitting mucoid edema, en-
largement of the thyroid gland, spleen, liv-
er, microcytic hypochromic anemia, leuko-
cytosis and monocytosis, with 10 per cent
mortality.

The chronic stage follows the acute form
or begins as such in adults. The symptoms
are very protean, depending upon the locali-
zation of the parasites. Cardiac, menin-
goencephalitic, myocardial, adrenal and ova-
rian types are described, with fever, anemia
and leukopenia.

A differential diagnosis must be made
from endemic, exophthalmic goiter, myxed-
ema, hookworm disease and Addison’s dis-
ease.

Laboratory Diagnosis: Thin and thick
films of blood during the febrile stage show
the trypanosome in the blood. Biopsy of
lymph glands, lacrymal gland, and cultiva-
tion of infective material on the N.N.N.
medium, xenodiagnosis, and inoculation into
guinea pigs, rats and mice are also used.
Complement fixation, agglutination and
skin tests are also very helpful.

Treatment: This is symptomatic. No
eminently satisfactory drug has been found.

It is probable that any or all of the hemo-
flagellate diseases may be brought back to
the United States by returning troops who
become infected in tropical areas where
these diseases are endemic, but it is not
likely that they will become established.
Visceral leishmaniasis is present in several
foci in South America and mucocutaneous
leishmaniasis is widely distributed from
Southern Brazil to Yucatan ; but the chances
of these diseases becoming established in the
United States are relatively remote, since
the sandfly vector is very restricted in its
breeding grounds in America north of the
Rio Grande. Since the tsetse fly, the vector
of African trypanosomiasis, is present only
in Africa, there is no possibility of this dis-

ease becoming established in the Americas
unless the vector first becomes adapted to
American soil. Apparently the environ-
ment factors are unfavorable for the tsetse
fly in the Western Hemisphere, else this
would have occurred years ago. American
trypanosomiasis (Chagas’ disease) is pres-
ent in many of the Latin American repub-
lics and the causative agent, insect vectors
and reservoir hosts have been found in the
southwestern United States, but thus far no
human cases have been reported in this
country. This last infection is the only one
of the hemoflagellate group in which au-
tochthonous cases may be discovered.

o

FILARIASIS AND SCHISTOMIASIS

ERNEST CARROLL FAUST, Ph. D.

New Orleans

FILARIASIS

Introduction: There are six commonly

recognized filaria worms which infect man.
Two species, Acanthocheilonema perstans
and Masonella ozzardi, live in body cavities.
They have embryos (microfilariae) which
are “unsheathed” and circulate in the peri-
pheral blood both day and night. These
forms are not known to produce lesions and
their infections may be regarded as essen-
tially without symptoms. The loa worm,
Loa loa, as an adult migrates through the
subcutaneous tissues and from time to time
crosses in front of the eye (i.e., under the
corneal conjunctiva), producing fugitive
swellings in its wake but otherwise causing
no serious disturbance. Its microfilaria
is “sheathed” and is more abundant in peri-
pheral blood during the daytime than at
night. A fourth species, Onchocerca volvu-
lus, is immured as an adult in a fibrous
matrix in the submucosa, most frequently
on the head, neck, or at the junctions of the
long bones. The microfilariae of this species
do not enter the circulating blood but mi-
grate through the cutaneous and subcu-
taneous tissues, especially in the lymphatic
capillaries. They tend to enter the eyeball
or optic nerve and are associated with a con-
dition of diminished vision and eventual
blindness.

Bancroft’s filaria ( Wuchereria bart-
er of ti) and the Malay filaria ( W . malayi)

116

Faust — Symposium — Tropical Medicine

live as adults in lymphatic vessels or near-
by lymphoid tissues. They discharge

“sheathed” microfilariae which get into the
blood stream and circulate through the
peripheral blood at night (that is, they have
nocturnal periodicity). Because of the

widespread distribution of these two fila-
rias, their almost certain pathogenicity and
their probable importance in the United
States as a result of their importation in
returning troops, these infections deserve
special emphasis. Filariasis malayi pro-
duces clinical manifestations essentially the
same as those caused by Bancroft’s filari-
asis. Since the latter type is much more
widely distributed in tropical war zones, it
will be considered at some length.

BANCROFT'S FILARIASIS

Pathogenesis : There is a negligible skin
reaction at the site where the mosquito in-
termediate host inoculates the infective-
stage larvae, but as weeks go by there is
from time to time an acute inflammatory
reaction where the growing larvae tem-
porarily block small lymphatic vessels or
lodge is lymph nodes. Towards the end of
the biological incubation period (about one
to one and a half years after exposure) the
adolescent worms tend to settle down in
lymphoid tissue in the vicinity of the sper-
matic duct, the epididymis or the groin.
Here they mate and the females discharge
daily broods of microfilariae. Subacute
cellular infiltration takes place around the
parent worms but essentially no reaction
is provoked by the circulating microfilariae.
There is typically a recurrence of the in-
flammatory reaction around the adult
worms, resulting in increased blockage of
lymph flow. Eventually, as the worms be-
come moribund, they are calcified and en-
capsulated in a fibrotic matrix. The fibro-
sis of lymphatic vessels and surrounding
tissues gradually extends retrograde to the
dying or dead worms, with ensuing vari-
cosity of the involved lymphatics and fre-
quently with elephantiasis.

Symptomatology: No symptoms develop
immediately following exposure, but with
the migration of the larvae into lymphatic
vessels, their growth and the discharge of

manifestations and later a fugitive lymph-
angitis, especially in the axilla, groin or vi-
cinity of the external genitalia. Then there
may be long periods of remission, but with
the anticipation of recurrent attacks of
lymphangitis with fever (“filarial fever”).
Eventually varicose groin glands will de-
velop, or a non-pitting elephantiasis of the
genitalia or lower extremities. There may
be chylous ascites, or chyluria, if a fistula
or rupture occurs as a result of pressure
within blocked lymphatics. Due to greatly
diminished blood flow in the surface tissues
of elephantoid areas, the skin cracks open,
allowing pyogenic bacteria or fungi to gain
entry, with the production of ulcers, ab-
scesses or septicemia.

All of the above pathology may be pro-
duced within five years, but more frequently
the development of the chronic picture of
the disease requires twenty or more years.

Diagnosis : Suspected cases of Bancroft’s
filariasis give a history of having lived in
endemic areas, with frequent exposure to
the bites of domestic mosquitoes. They may
have had one or more episodes of urticaria
or other allergic manifestations and have
had one or more attacks of lymphangitis,
usually accompanied by fever. If the bio-
logical incubation period is still incomplete,
microfilariae can not be demonstrated, but
as soon as the worms become adult and as
long as they are alive, “sheathed” micro-
filariae will be found in thick blood films
(typically at night, especially between mid-
night and two a. m., but in the endemic
South Pacific area at all hours of the
twenty-four). In other patients the micro-
filariae may be present in urine (in patients
with chyluria), in ascitic fluid (in patients
with chylous ascites), or may be demon-
strated in biopsied material or at operation.
In the most chronic cases the parent worms
will have died long since and microfilariae
will not be found in circulating blood, but
the visualization by x-ray of minute grape-
like clusters of calcified granules in the cen-
ter of the lesion at the head of a blocked and
varicosed lymphatic vessel is pathogno-
monic.

Prognosis : This is good in so far as life

Faust — Symposium — Tropical Medicine

117

is concerned, but the eventual prognosis
with reference to the development of
chronic sequelae is poor.

Treatment : No satisfactory chemother-

apy has yet been found to kill the parent
worms, or more important, to reduce the
chronic lesion. A modified Kondolean oper-
ation is temporarily helpful in reducing
elephantiasis of an extremity but the condi-
tion usually recurs in about five years.
Radical operation for elephantiasis scroti or
varicose groin gland is frequently success-
ful. Tight bandaging of an elephantoid ex-
tremity will usually be helpful in forcing
blocked lymph into collateral channels and
thus considerably reduce the elephantoid
tissue. Sulfonamides or autogenous vac-
cines are useful in treating bacterial com-
plications.

Prevention : Bancroft’s filariasis is

propagated by several species of domestic
mosquitoes ( Culex , Aedes, et alii), which
breed in small household water containers
or puddles of water near human habi-
tations. Emptying water containers
(cans, earthenware and glass jars) every
four or five days and draining or filling
low places where rainwater accumulates
are measures of first importance, since the
infection depends on mosquito transmission.
Screening of homes and the use of mosquito
repellents will minimize exposure of unin-
fected persons. Finally, infected patients,
including carrier cases, temporarily asymp-
tomatic but with microfilariae circulating in
their blood, should be screened so that mos-
quitoes will not become infected. In pro-
portion as these measures are diligently car-
ried out the dangers of this disease will be
reduced.

Several decades ago Bancroft’s filariasis
was widely endemic throughout the south-
eastern United States and until recently
was present in the vicinity of Charleston,
S. C. Today, it is probably no longer an
endemic disease, but with the importation
of many hundreds of cases in, returned
troops from the South Pacific areas, some
of them at the , threshhold of becoming
transmitters, there should be an awakened
consciousness of physician and layman

alike, concerning the potential danger of do-
mestic mosquitoes, such as was developed in
New Orleans in 1905 at the time of the last
yellow fever epidemic. War on domestic
mosquitoes is always good prophylaxis, but
is particularly good strategy at the present
time.

SCHISTOSOMIASIS

Introduction : There are three species of
schistosomes (helminths belonging to the
Class Trematoda, family Schistosomatidae)
which parasitize man. All of them inhabit
venules draining visceral organs, hence the
name “blood fluke.” Two species, Schisto-
soma japonicum and S. momsoni live in the
mesenteric venules draining respectively the
small and the large bowel. They produce
primarily intestinal and hepatic damage.
The third species, S. haematobium , lives in
the vesical plexus and produces lesions prin-
cipally in the urinary bladder.

Migration and Maturity of the Etiologic
Agents in the Human Body. Man is ex-
posed to schistosome infection when he
bathes, swims, wades or otherwise brings
his skin in direct contact with fresh water
containing the fork-tailed larvae (cercar-
iae) of these flukes, which have previous-
ly undergone development and two-fold
multiplication in certain species of fresh-
water snails. As the “infected water”
drains off the skin, the larvae become at-
tached, drop their tails, and digest their way
down to the peripheral venules. In about
twenty-four hours they enter afferent ven-
ous blood vessels and are carried through
the right chambers of the heart to the lungs.
They require about four days to squeeze
through the pulmonary capillaries, are then
carried through the left chambers of the
heart and out through the aortic arch. The
majority pass down through the thoracic
and abdominal aorta to the mesenteric ar-
tery and pass through into the portal blood,
where they lodge and begin to feed on whole
blood. All larvae which become lodged out-
side the mesenteric system die and many
produce petechial hemorrhages. Once with-
in the intrahepatic portal system the larvae
grow and in sixteen days (that is, about
three weeks after skin exposure) are large

118

Faust — Symposium — Tropical Medicine

enough and strong enough to migrate out of
the liver against incoming portal blood.

The young of Schistosoma japonicum get
into the mesenteric venules draining the
small bowel, mature, mate and the females
begin to lay eggs about four to five weeks
after skin exposure. Those of S. mansoni
reach the venules draining the large bowe1
and egg-laying is initiated ?(bout isix |to
seven weeks after skin exposure. Those of
S. haematobium migrate down through the
inferior mesenteric veins, pass through the
hemorrhoidals or pudendals and reach the
vesical plexus, where egg-laying begins
about ten to twelve weeks after skin ex-
posure.

Pathogenesis : This is divided into three
successive stages: (1) the incubation

period, (2) the acute stage and (3) the
chronic stage.

The incubation period is initiated with
the entry of the schistosome larvae into the
skin. There is relatively little tissue reac-
tion at the sites of penetration but an acute
cellular infiltration occurs during passage
through the pulmonary capillaries. More-
over, wherever the migrating larvae break
out of capillaries or lodge in blind foci, they
cause petechial hemorrhage. As the worms
accumulate in the intra-hepatic portal ves-
sels an acute periportal inflammatory re>
action to the by-products of the developing
worms occurs, indicated by an intense eosin-
ophilia. These conditions approach a climax
towards the end of the incubation period.

The acute stage is ushered in as the eggs,
layed in the smaller venules in the muscular
or submucous coats of the involved organs,
work their way through the several layers
of the organ into its lumen, with resultant
traumatic and lytic damage to the cells.
There is continued local and systemic re-
action to the toxic by-products of the worms
and their eggs, as evidenced in part by a
profound eosinophilic leukocytosis.

The chronic stage almost imperceptibly
succeeds the acute stage. In increasing
numbers the eggs discharged by the female
worms become temporarily lodged in the
tissues and provoke the formation of ab-
scesses which usually transform into

pseudotubercles. These miliary pseudo-
tubercles are from this time on the cardinal
pathological processes and are centers for
the development of fibroses, cicatrices and
papillomata of the small bowel ( S . japoni-
cum) , of the large bowel (S. mansoni) and
of the urinary bladder ( S . haematobium).
Moreover, in the intestinal forms, but par-
ticularly pronounced in S. japonicum infec-
tion, the eggs escape into the larger mesen-
teric venules, are carried back into the liver
and mesenteric lymph nodes and produce
cirrhosis of these organs. With liver in-
volvement the spleen compensatorily be-
comes greatly engorged and, as the hepatic
cirrhosis proceeds, ascites develops. In
the vesical type there is marked deposition
of phosphatic salts in the bladder wall and
uric acid crystals around eggs which are ex-
pelled into the lumen of the bladder. There
is an occasional carcinoma of the rectum
(especially in S. masoni infection) or of
the bladder (S. haematobium infection).
There is frequently a development of pseu-
dotubercles in the lungs and involvement of
the genitalia in the vesical type. Pyogenic
infections may complicate the late chronic
stage of S. haematobium infection. The
leukocytosis of the acute stage changes to a
neutropenia and monocytosis, but with a
moderate eosinophilia. There is an increase
in serum euglobin.

Symptomatology : The incubation period
is initiated with a needling pain at each site
of skin inoculation. There is a tendency to
allergic, states, particularly giant urticaria,
first at the time when many larvae which
have miscarried die in blind termini, and
again as the toxic by-products of the grow-
ing worms become distributed throughout
the system. Little by little the liver be-
comes enlarged and exquisitely tender. In
the intestinal forms there are prodromata
of late afternoon fever and night sweats,
and a few days before the end of this period
a rather profuse mucous diarrhea develops.

The acute stage in S. japonicum and S.
mansoni is ushered in with intestinal dis-
comfort, frequent desire to defecate and the
passage of a dysenteric stool. In S. man-
soni infection there is more tenesmus than

F aust — Symposium — Tropical Medicine

119

in S. japonicum. The patient is practically
prostrate and goes to bed. This acute con-
dition continues for two or three weeks, but
with rest in bed it gradually subsides and
the patient gets up, at times undertaking
light work. With exercise the dysenteric
condition recurs, so that only prolonged
rest brings relief. In the vesical form the
acute stage begins with the painless passage
of blood at the end of the period of urina-
tion, but soon there is a burning sensation
at times of micturition, bladder colic and
the terminal discharge contains not only
blood but purulent debris.

As the chronic stage comes on in the in-
testinal types there is increased digestive
and hepatic dysfunction, leading to malnu-
trition and emaciation on the one hand and
ascites and splenomegaly on the other.
Moreover, the greatly enlarged spleen and
mesenteric lymph nodes and the fibrosis of
the mesentery push the diaphragm upwards,
with consequent decrease in the size of the
chest box and thus in the vital capacity of
the lungs. In the vesical type there is in-
continence with respect to the passage of
urine, frequently complicated with bladder
stone. Pyogenic infections may be sequelae
to both the intestinal and vesical types of
infection, but more frequently, the latter.
Similarly, the chronic irritation of the
fundus of the bladder tends to produce car-
cinoma of this organ more frequently than
of the rectum, although prolapsus recti is
not infrequent. Occasionally the vesical type
secondarily involves the rectum, although
it more frequently produces disease proc-
esses in the genitalia and the lungs. Death
characteristically results from inanition,
pneumonia or sepsis.

Diagnosis : Among natives in endemic
areas it is rare to see schistosome infection
in the incubation period or as a pure acuta
infection, usually because exposure over a
period of years gives a picture of the acute
state superimposed on chronic infection.
Frequently the history of the patient is sug-
gestive, that is, having lived in an endemic
area, and having bathed in potentially “in-
fected water,” or having had episodes of

dysentery, hematuria or bladder colic, espe-
cially after physical exertion.

During the incubation period giant urti-
caria may provide a lead or during the lat-
ter part of this period a tender, enlarged
liver with a high eosinophilia may suggest
a tentative diagnosis. Specific diagnosis
must wait until the beginning of the acute
stage, when the eggs are discharged in the
stool, especially in flecks of blood and mucus
(S. japonicum, S. mansoni) or in the urine,
especially with blood and mucus in the last
few cubic centimeters (S. haematobium).
If eggs are few in the stools, repeated sedi-
mentation with decantation will be helpful
in concentrating the eggs in the bottom sedi-
ment. In the vesical type the sediment
from urine passed directly into an 8-ounce
urinalysis glass usually contains the eggs of
S. haematobium.

Prognosis : This is fair to excellent for
cases with acute and early chronic infection,
provided specific therapy is undertaken ; al-
ways poor for late chronic stages with he-
patic involvement or carcinoma.

Treatment : Antimony preparations are
specific for all types of schistosome infec-
tion. Tartar emetic and sodium antimony
tartrate are the salts most commonly em-
ployed intravenously. The former is the
more stable preparation; the latter is bet-
ter tolerated by the patient. Sterile solu-
tion of 2 to 6 per cent is administered in-
travenously three times a week, beginning
with 1.5 c. c., then 3.5 c. c. and 5 c. c., and
continuing if possible with the 5 c. c. dose
until 1.35 gm. (20 gr.) have been adminis-
tered (four weeks for 6 per cent solution,
12 weeks for 2 per cent solution).

Fuadin (stibophen) and anthiomaline are
employed for intramuscular injection. They
are more easily administered and better tol-
erated than the antimony tartrates but they
less frequently produce a cure in one course
of treatment. They are prepared commer-
cially as a 6 per cent or 7 per cent solu-
tion and are given as follows : first day, 1.5
c. c. ; second day, 3.5 c. c. ; third day, 5 c. c.,
then 5 c. c. on alternate days or every third
day until a total of 50 c. c. has been admin-
istered.

120

Stubenbord — Recurrent Malaria in Military Personnel

For cases with advanced hepatic cirrhosis
specific therapy is useless.

Prevention: This should be planned in
two ways, one for temporary exposure in an
endemic area, the other for eradication of
the infection.

Temporary protection requires that in-
dividuals or groups refrain from bathing
or otherwise utilizing “infected water” (or
water under suspicion of containing the
schistosome larvae) until it has been hyper-
chlorinated, well filtered or boiled, or has
stood for at least 24 hours in a snail-free
container. Circumscribed bodies of fresh
water under suspicion should be treated
with copper sulphate (one volume for each
50,000 volumes of estimated water), to kill
the snails and their schistosome cercariae.
Natives should not be allowed to pollute wa-
ters within a mile of a campsite.

For permanent control provisions should
be made for the sanitary disposal of all hu-

man excreta. This requires a long-time ed-
ucational program to secure compliance of
native populations. In addition, some re-
duction of the infection may be expected
from subjecting snails in endemic areas to
desiccation, quicklime or live steam, and
from treating all infected persons with an-
timony.

Schistosome infections have never be-
come established endemically in the United
States, Mexico, Central America, Cuba or
Jamaica, although many negro slaves
brought in these diseases in past centuries.
While the possibility of endemicity should
not be excluded, the likelihood is scant. On
the other hand, there is great likelihood that
many cases of these infections will be
brought into the country in returned troops,
so that physicians should be cognizant of
the clinical features of this disease group as
well as of the potential dangers of estab-
lishing them in this country.

RECURRENT MALARIA IN MILITARY
PERSONNEL

WILLIAM D. STUBENBORD,

LT. COMDR. (M.C.) U. S. N. R.

New Orleans

Malaria will probably be one of the great
medical problems of the general practitioner
after the war. Soldiers, sailors, marines,
and civilian employees who contracted ma-
laria in tropical and subtropical areas will
be returning to the United States as car-
riers and recurrent patients. These people
will, therefore, be a potential source of va-
rious tropical strains of the malaria plas-
modia. Civilian practitioners of medicine
may be called upon to treat these individ-
uals. It is of utmost importance that these
physicians be familiar with the symptoms
and be alert to diagnose and treat correctly
these patients so as to prevent the spread
of malaria. It is possible that local out-
breaks of malaria may occur in this coun-
try, starting from relapsing cases acquired
abroad. The United States Public Health
Service recognizes this possibility and is
carrying out intensive anti-mosquito pro-
grams. Physicians can aid by early diag-

nosis, by reporting of cases, by adequate
treatment and by mosquito control. It is
well known that the anopheles quadrimacu-
latus mosquito is present in Louisiana and
is therefore of particular importance to lo-
cal physicians. Great care should be used
to see that all patients with malaria, includ-
ing those with relapses, be protected from
mosquitoes by a bed net or be treated in a
ward made free of mosquitoes by chemical
means.

Relapses are characteristic of all types
of malaria but are particularly prone to
occur in cases infected with the strain of
plasmodium vivax acquired in endemic
South Pacific Islands. It is not unusual
for a patient to have ten or more relapses.

Relapses may occur without obvious cause
but are most apt to follow any condition
that lowers body resistance, such as ex-
posure to cold, alcoholic, dietetic, or vene-
real excesses, intercurrent infections, a se-
rious accident, a surgical operation, child-
birth, or exertion of routine military life.

A relapse may occur after a remission of
six to eighteen months. One reason why re-
lapses occur is the fact that many cases of

Stubenbord — Recurrent Malaria in Military Personnel

121

malaria are not adequately or completely
treated during their initial infection. The
parasites become lodged in the organs and
tissues of the body, especially in the spleen
and bone marrow where they are further
protected from drugs. It is generally be-
lieved that relapses are due to a failure of
the defensive forces of the body to restrict
the multiplication of the parasites to negli-
gible proportions, as they do during the
latent stages of infection.

There is no known drug which will pre-
vent relapses. Until some drug is discov-
ered which will attack the sporozoites be-
fore they continue their life cycle the likeli-
hood of recurrences is probable.

Quinine, atabrine and plasmochin are the
drugs most commonly used for treatment.
Quinine and atabrine act on the schizonts
and trophozoites of all phasmodia affecting
human beings. Plasmochin, a quinoline de-
rivative, acts primarily on the gametocytes
(the sexual forms). All three drugs are
however alike in their inability in a certain
number of cases to cure permanently, that
is, without the occurrence of relapses. They
also fail in safe doses to prevent maturation
of the merozoites.

The treatment which we are following at
the Naval Hospital in New Orleans is the
combined quinine, atabrine and plasmochin
plan recommended by the Subcommittee on
Tropical Diseases of the National Research
Council. The plan is as follows:

1. Quinine sulfate 0.64 gm. (10 grains)
three times daily after meals until pyrexia
is controlled.

2. Then atabrine dihydrochloride 0.1 gm.
(IV2 grains) daily after meals for five
days.

3. Two days of no antimalarial medica-
tion.

4. Then plasmochin 0.01 gm. (3/20
grain) three times daily after meals for
five days. Discontinue if toxic symptoms
appear. Never give atabrine and plasmo-
chin concurrently.

It is extremely important that physicians
be aware of falciparum infections since they
are prone to cause cerebral symptoms and
may even terminate fatally. The symptoms

may be so obscure that malaria is not sus-
pected and coma or even death may occur
before the diagnosis is made. It is there-
fore essential that adequate and early treat-
ment be instigated. Clinically, malaria
should be suspected in any person with any
complaint whatever if that individual has
recently returned from the Tropics. Repeat-
ed smears should be made before a case is
not considered to be malaria.

The following case is presented to illus-
trate some of the points brought out in this
discussion.

CASE REPORT

I. M., ship’s cook 2nd class, U. S. Navy, age 22,
of New Orleans, states that when he left the
United States in March 1943 he started to take
atabrine daily under the supervision of a pharma-
cist’s mate as suppresive treatment. He was first
taken ill with malaria in Guadalcanal on June 16,
1943. He had symptoms of malaria for three
weeks before his condition was definitely diagnosed.
At that time he complained of headaches, chills
and fever. On July 20, 1943 the plasmodium vivax
was demonstrated on blood smear and according
to his health record he was given quinine 2 grains
every four hours a day and night for three days,
along with atabrine gr. 1% three times a day.
After a rest of two days, plasmochin gr. 1/3 was
given every night for five days. Despite this
treatment he still continued to run a fever of
101° or more.

On August 29 smears were still positive for
plasmodium vivax and 6 grains of quinine was
given daily for 14 days. On September 18 smears
were negative although he continued to run an
occasional temperature up to 100°.

He was evacuated to the United States and on
October 5 was admitted to the U. S. Naval Hos-
pital, Oakland, California. At that time it was
noted the patient had been complaining of chills
and fever every two to three weeks and that smears
for malaria remained positive. Physical examina-
tion showed the patient, to be well developed but
somewhat undernourished, with a weight loss of
25 pounds. The spleen was palpable, one finger
below costal margin.

A smear on October 8 was positive for malaria
(plasmodium vivax). He was again treated with
quinine and atabrine, along with bed rest. Fol-
lowing this he was given quinine, 10 grains twice
a day, and sent to the Convalescent Home at Santa
Cruz, California on November 16. After being
there for a month he was given a convalescent
leave. While at home he had another chill and
at this time he took 30 grains of quinine for two
days. He was admitted to the U. S. Naval Hos-
pital, New Orleans, on January 3, 1944, having

122

Watters — The Patient- Physician Relationship

another chill and temperature up to 103.2°. Smear
was positive for plasmodium vivax. He was now
given quinine, 6 grains three times a day, for
five days and then quinine 6 grains with plas-
mochin gr. 1 '6 three times a day, for five days.

Since being in this hospital he has had two
more relapses with positive smears. With his
last relapse he was put on the combined quinine,
atabrine and plasmochin regime outlined previous-
ly. For over two months now he has been symp-
tom free and his general health has improved.

SUMMARY

1. This case shows that this individual
developed malaria despite the fact that he
was taking suppressive treatment under
careful supervision.

2. Treatment failed to prevent the oc-
currence of relapses and this patient has
had 15 to 20 relapses in a period of about
six months.

3. Quinine, atabrine and plasmochin giv-
en by the method suggested by the Subcom-
mittee on Tropical Diseases of the National
Research Council seems to be the most ef-
fective plan of treatment.

o

THE PATIENT-PHYSICIAN
RELATIONSHIP*

T A. WATTERS, M. D.f
New Orleans

The patient - physician relationship is
something many of us take for granted and
to which we give little thought, particularly
to the psychodynamics involved. Yet there
are few, if any, professional men of clinical
experience who will deny its profound im-
portance. Perhaps one of the best ways to
reach an understanding of what precisely is
involved in this relationship, is to approach
it through historical perspective.

This relationship is an ancient one, pos-
sibly one of the oldest to be recorded and
catalogued in the chronicles of human ex-
perience. Certainly, it can be traced back
to the medicine man of tribal life, and
whether we like it or not, we are direct

*Read before the sixty-fifth annual meeting of
the Louisiana State Medical Society, New Orleans,
April 24-26, 1944.

fFrom the Department of Medicine, Division
of Psychiatry, of the School of Medicine, Tulane
University of Louisiana, New Orleans.

descendants of this worker of magic. While
incantations, thaumaturgy, and rituals, op-
erating through fear and wonderment in
his subjects, he wielded a potent authority
over their minds by investing herbs, am-
ulets, and charms with special power, thus
using the well known principle of indirect
suggestion. He was only too often a suc-
cessful therapeutist. His methods, how-
ever, encouraged uncritical attitudes so
characteristic of primitive, pre-logic think-
ing.

As medicine moved down the centuries,
with a shifting from magic to mysticism,
the high priests of each respective civiliza-
tion took over to a large extent the respon-
sibility for the sorrows and sicknesses
which beset their flocks. Finally, time
brought Hippocrates, who delivered medi-
cine from much of its magic and some of
its superstition, and by emancipating it
from theologic restrictions, gave impetus to
its development as a discipline in its own
right. Time again was kind when it molded
a man of unusual qualities, unselfish, in-
domitable, consecrated to the alleviation of
human suffering, the family physician.
This man held a big place in the hearts
and lives of his patients in a society built
around strong paternal figures. He was
deeply respected in his community, not only
as a good doctor, advisor, and friend, but
as a leader of civic action and thought.
Often he was a poor business man who
neglected to collect money for his services
or invest what he had with shrewdness, but
generally he reaped bigger rewards in suc-
cessful healing. His relationship with his
patient was vested in authority, but his
opinions were tinctured with humility, and
his advice with benevolence and under-
standing. In the America of those days,
transportation was difficult, and small com-
munity life prevailed. But no little farm
was too distant to be inaccessible to the
doctor and his horse. The life of an old
patient waiting upon his skill, or a new
baby to be brought into the world as he had
brought the father before him, was an im-
perative call. He was the mainspring of
community life, servant and confessor to

Watters — The Patient-Physician Relationship

123

all, a real sociologist and philosopher, and
a keen student of human nature. All the
gossip of his little world came to his ears,
and he never became too detached from it
to lose sight of his patients as people, in-
stead of walking disorders. The city doctor
of this era also shared this viewpoint of
treating the man rather than his complaint,
and similarly played a part truly paternal
in the lives of his patients. Professional
reserve was maintained by writing pre-
scriptions in Latin, and medical matters
were discussed sufficiently to meet the pa-
tient’s therapeutic needs and allowed to go
at that — a method still effective today.
Every great discovery in medicine was not
given out in scientific detail, to be garbled
by popular publications, on the premise lay-
men must be completely informed. He
knew too much information could bewilder,
confuse, and create more symptoms. The
point is, that he kept much of his thera-
peutics and many of his tricks to himself.
He knew that logic was better than magic,
but he did not deceive himself by thinking
people reason, when mostly they rational-
ize; by thinking people use science when
mostly they use supposition.

When we entered upon an era of rapid
transit and streamlined treatment, the fam-
ily physician lost his unique place. Clinics
and cliques entered the picture, bringing
much that was good, but also losing much
that was valuable along the line. We be-
came intoxicated with the scientific method.
We broke man into segments. We dissected
him, we put him under the microscope, we
took pictures of his functions and sub-
functions, on and on, with the yen to break
him down into miniscules of matter: veri-
tably a pedagogical quirk devoid of holism,
respect for the laws of biology — essentially
a progressive dehumanizing of man. I
would add, however, that I have no quarrel
with science, merely with the manner in
which it is used and abused.

Fortunately, through the period when the
family physician was losing his place, the
psychiatrist, in spite of medical bigotry,
began studying and treating man as an in-
dividual, living in a social and cultural

milieu. He thus came to appreciate the ne-
cessity for establishing and maintaining a
working relationship between his patient
and himself. The fact that he had to work
with disordered personalities, created prob-
lems for which he found new solutions
through the study of the patient-physician
relationship, which in turn led to an under-
standing of its psychodynamics. Thus he
should be credited with the discovery of its
real significance, and medicine can be
grateful for his fearless observations made
early in the century. Previously no scien-
tific effort had been given to a frank analy-
sis of human relationships, but rather they
were left to the poets and romanticists;
psychiatrists, however, made them the
province of the physician.

I would like to mention a few of these.
Beginning with the relationship of the one
to the many, we find lecturer and audience,
captain and company, leader and mob, Hit-
ler and henchmen. Relationships with a
strong sexual component add parties to an
engagement or marriage, crushes, homo-
sexual affairs, and the mercenary one be-
tween prostitute and patron. Less lurid is
simple acquaintance and friendship, em-
ployer and employee, and on a professional
level, we find teacher and pupil, lawyer and
client, priest and parishioner, and finally,
the physician and his patient.

This relationship begins when the patient
makes his decision to consult his doctor. It
becomes a concrete reality when he lays
eyes upon him for the first time, and may
well have received a bias from the hand-
shake, manner, or address used by his
physician on this occasion. We must re-
member this patient-physician relationship
is highly charged with the imprint of cen-
turies which have slowly conditioned both
parties to expect certain things of each
other. The physician is expected to be a
man of learning and experience, depend-
able, understanding, and motivated by a
strong sense of responsibility. What in turn
do we expect from our patient? A person
possibly more informed and critical than
his forefathers, conditioned by a highly in-
tellectualized environment, yet suggestible

124

Watters — The Patient-Physician Relationship

as man always has been ; one torn by hope
and fear, yet amenable to treatment in the
setting of a healthy doctor-patient relation-
ship, in which there is sufficient emotional
detachment to avoid personal involvement.

This relationship takes place in a frame-
work of formality and propriety, actually
functioning in the medium of conversation,
which is skilfully directed by the physician
as a rhetorical - logical process. Thus
through ideas are made analyses, interpre-
tations and syntheses, concepts and atti-
tudes are exchanged, advice and sugges-
tions are given. It has been said that
“Words are like magic.” They are at once
the weapon which the physician uses to
eombat virulent ideas fermenting in the
mind of his patient and the wedge to intro-
duce a more benign strain therein. For
malignant bacteria at work in the body are
not more deadly than poisonous ideas with-
in the mind, or multiplying in a society
with whose customs and regulations one is
at odds. On the other hand, wholesome
ideas properly introduced and incubated,
contribute to therapeutic success.

Beneath the flow of tendentious conver-
sation between patient and physician, move
the emotional processes, carrying positive
and negative forces which strengthen or
sever the relationship between them, and
more than all else, hasten or retard the pa-
tient’s recovery. For example, these emo-
tions may be associated with unpleasant
events and experiences, may contribute to
the making of strong attitudes toward life
and an earnest wish for recovery, or para-
doxically, they may perpetuate his symp-
toms and lead him to evade diagnosis.
Emotional processes were at one time man’s
most effective means of communication and
adjustment, particularly when his language
was unverbalized and consisted mainly of
hoots and howls, squawks and squeals,
crows and cackles. They are still at work
today, giving color and meaning to his
rhetorical - logical processes, integrating
them with the organ systems and organs
into “total” functions, or behavior, deter-
mined by his environmental needs of the
present, with conditioning from the past

and with anticipation for the future. Blend-
ing with these processes, the most potent,
the most primitive, and the most barbaric
forces of all, lie in wait for an opening —
the instinctual processes, demanding real-
ization of life’s fundamental biological prin-
ciples. We then have at our disposal and
co-temporaneously in operation, this whole
gamut of man’s mental processes focused to
symbolization in consciousness while we are
engaging him in conversation for clinical
obeervation and study. Hence we see that an
appeal to all these components cannot be
neglected by the astute physician, for the
freeing of these emotional forces may
loosen or completely alleviate his symptoms.
In the emotional process is found, moreover,
the catalyzer which will promote an ef-
fective relationship smoothing the path to
therapeutic success.

Of greatest moment is the physician’s
personality. He will become increasingly
aware of the importance of acquiring such
social assets as tact, amiability, composure,
and sincerity, discreetly seasoned with a
dash of kindly humor and reserve. Above
all, he must train himself to become a con-
structive listener. Time must be given the
patient to ventilate his troubles, while skil-
fully guiding him in order to extract much
valuable information without his being
aware of it, thereby getting the story be-
hind the story without brusque cross-exam-
ination. The doctor must never give the
impression he is too busy to listen, and in
a hurry to dismiss the patient, pressed as
he may be for time. He thus courts the
emotional cooperation of his patient there-
by fostering a smooth, effective esprit de
deux.

Such relationship once established, char-
acterized by an emotional attunement be-
tween them, is called “en rapport” or “rap-
port.” It means oneness in thought and
action ; a co-participation in mutual assist-
ance and understanding; an understanding
directed toward the essential goal of recov-
ery in the one who is sick. Clinical experi-
ence teaches us that quick appraisal of the
patient’s emotional make-up and his atti-
tude towards his illness, therefore, should

Watters — The Patient-Physician Relationship

125

be one of the first things to ascertain.
Whether his disorder be organic, function-
al, or a mixture of both, comes to the same
thing when he is being treated as a person
who is sick. What matters is to understand
his emotional functions in order to use them
consistently throughout the therapeutic re-
lationship in diagnosing, treating, and man-
aging the person and his disorder through
his recovery and readjustment to life.

There are various theories about the emo-
tional bond between the patient and his
physician. For instance, the Freudian
thinks of it, not as “rapport,” but as “trans-
fer.” By this, he means that the patient
transfers his love and affection from his
primary love object to the physician: the
physician playing the role of father, mother
substitute, etc. Here the physician must be
careful not to become emotionally involved
with his patient while playing a therapeutic
part, and at every stage have in mind the
eventual weaning of the patient from him-
self as love-object, and diverting the famous
Freudian libido, to socially suitable persons.
Adler, another prominent psychiatrist, took
this same libido, gave it a Nietzchean twist
into the will to superiority, which must be
pruned to decorous dimensions or induced
to grow to adequate stature. The skilful
psychiatrist can be helpful in both in-
stances. Jung was intrigued by the un-
plumbed depths of man’s collective uncon-
scious and the powers residing therein.
Here he found enormous historic and aes-
thetic content which incited the libido to
play versatile roles. He traced man’s psy-
chic evolution through the ages as others
have traced his physical evolution. He un-
covered the source of mythology and
showed that even now gods and devils walk
the earth in the shape of archetypes within
one’s unconscious mind. Certain archetypes
were to be traced in all men, which had
slowly evolved through experiences com-
mon to the race in its slow evolution. To
Jung, one might be the idea of the physi-
cian, for example, and a less ancient one
stemming from this, the family physician.
Whenever a human being approximates one
of these archetypes, he fixes upon himself

the unconscious love or hatred which the
archetype itself provokes. Such a figure is
Hitler, who has crystallized the fanatical
devotion of a people who love the tyrant
archetype, and the hatred of those who
reject it.

The psychiatrist who borrows from the
different “schools” their valid teachings
and uses them with a middle-of-the-road
technic, might be considered an eclectic:
he avoids bias and tenetical restrictions,
neither exploits the patient for his own re-
search, nor holds him under treatment for
ransom. A similar therapeutic procedure
is the best one for the general physician
who is working in a framework of many
human diseases and disorders, meanwhile
maintaining through successful rapport, a
working relationship with his patient.

The art of medicine can never dispense
with these principles of psychotherapy, they
should be known by every physician, re-
gardless of his field of work, and are not
too difficult to assimilate if he will devote
some time and effort towrard acquiring
their theory and technics. After all, these
fundamentals of psychotherapy are nothing
more than a means of handling those who
are disturbed, disordered, or diseased, and
are not to be thought of as hocus-pocus, or
spoken of derisively as “boloney.” Rather
psychotherapy is a legitimate part of the
art of healing. Foremost for its application
is a sound, smooth patient-physician rela-
tionship, something about which all the dif-
ferent “schools” agree.

We have seen that it has evolved through
centuries of mutual experience uniting lay-
man and doctor. It is something of which
we may well be proud and should guard
at all costs, since our patients confide to
us "hings which even a devout Catholic con-
science would not yield to his priest. Pause
and think about this. ... It indicates the
great faith society holds in us as profes-
sional men. It is protected by law in every
land, with the possible exception of fascist
countries. It has been given the near
sanctity of a true family tie, filial and de-
pendent on the one hand, paternal and pro-
tective on the other, only broken in those

126

Watters — The Patient-Physician Relationship

countries which have attempted to stamp
out family loyalties and substitute the su-
preme welfare of the State. Yet I feel safe
in predicting that the ancient relationship
will survive this war, cherished by the de-
mocracies, and will be the first right re-
stored to the vanquished enemy lands, once
the war is over.

It is my humble opinion that the profes-
sion has become conscious of this relation-
ship through speakers and writers of the
day. In this era of scientific awareness
with its shiny toys and gadgets, somehow
we lost sight of the true nature of man, and
departed from the essentials of healing.
Certainly, a more careful appraisal of it is
paramount in both teaching and practice.
It is high time that medical education bring
itself to the task of promoting an earnest
effort towards a full and unbiased appre-
ciation of it throughout the medical stu-
dent’s tenure and contact with his faculty,
and widen the opportunity for a curriculum
in which reposes more time for instruction
in the fundamentals of the psychology of
this relationship. In times such as these,
it is utterly microscopic and mentally my-
opic to scoff at psychiatrists when they are
progressively giving more meaning to this
relationship, with all its implications in a
society of which we as professional workers
constitute a group. We are all uncomfor-
tably aware of incursions into this relation-
ship upon the part of people outside our
profession, who operate under the guise of
service to humanity, and feel divinely ap-
pointed to assume obligations evaded by
too many of our colleagues. Thus it is ob-
vious to all of us with socialized medicine
in the offing, that we should undertake in-
dividually and collectively a fuller ap-
praisal, enhancement, and use of this rela-
tionship. Socialized medicine may in part
be the expressed dissatisfaction and con-
fusion of a people who deserted the family
physician for the specialists, and now won-
der how many specialists it takes to make a
good doctor.

Apparently there has never been a
greater need for fine doctors. To the aver-
age patient this means those who under-

stand and use the opportunities that lie in
the doctor-patient relationship. For they
feel that within it, and deriving from it is
the amelioration and solution of many of
their personal and social ills. In fact it may
be said to be the basis and bulwark of all
treatment. Therapy starts and ends with
the relationship, regardless of what is done
in the interim, and as long as human beings
seek health and happiness, and fear disease
and disorder, this psychological tie between
them and the doctor of their choice, may
not be lightly dismissed as irrelevant and
immaterial either in the medical schools or
in actual practice.

Minds are being bombarded by conflict-
ing ideas and propaganda over the air, on
the screen, and in the press, associated with
which are the natural tensions born of the
highly competitive life in a war-torn world,
and whatever our profession can lend to-
ward the stabilization of the individual liv-
ing in this world will be deeply appreciated
by society at large. Our profession is one
dedicated to the whole man, not merely to
his organs and his functions; to his social
welfare, not merely to his health. Our duty
then, is to conceive of man as a social being,
a spiritual being, a mental being, and phys-
ical being, but above all, a human being!

DISCUSSION

Dr. C. S. Holbrook (New Orleans) : I think Dr.
Watters has brought to us in a very scholarly
presentation a most important relationship with
which we are all somewhat familiar. I do not
know of anything more important to the welfare
of our patients than the proper rapport between
the patient and physician. We might be almost
criticized for bringing this subject to a group
largely made up of this type of therapist, the
family physician, whose value is, in large part,
due to his interest in the patient as a whole and
not as a conglomeration of parts. His value also
depends upon the feeling that the patient has
toward him as a healer and helper. Psychiatry
largely depends on interpretation of these emo-
tional reactions and proper directing of them. We
have come to do it by training. The family phy-
sician has learned to do it from practice and in-
herent qualities that he has and his value de-
pends largely on that.

Unfortunately medicine has developed into spec-
ialties, reducing this very important aspect of
treatment because the specialist examines one part
of the patient — eye, nose or throat or for ortho-

Billings — Symposium — Syphilis

127

pedic conditions or determines how his gastro-
intestinal tract functions — and has very little
time for anything else. Quite frequently we find
that this type of examination reveals a perfectly
normal individual yet this individual is ill and
what he is looking for is an opportunity to get rid
of his fears, his tension state, and in the past that
has often been accomplished by the general prac-
titioner or family doctor. This can be done today
and is being done today. The specialist can and
is doing it today. A waiting room full of people
is certainly a detriment toward anything ap-
proaching psychotherapy. The most important
interview with a patient is the first interview.
They often unload their difficulties and problems
and various relations at that time better than at
any other time. If a physician is fortunate
enough to give an hour or an hour artd a half to
such an interview he will be practicing splendid
psychotherapy. The difficulty is to find the time,
however we should, in our various specialties and
contacts with the patient try to find out more
about the instinctive and emotional make-up of
the patient and in that way many difficult prob-
lems will be simplified.

Dr. J. H. Musser (New Orleans) : I hardly know
what to say on this very interesting subject that
Dr. Watters has presented so well. I rather
thought that his talk was going to be on some-
what different lines than it was.

What he has said, I think, is extremely worth-
while and certainly is something that gives us
food for thought. There is no doubt at all that
the patient-physician relationship is extremely im-
portant and that there are some doctors who can
get “en rapport” very rapidly and promptly and
those are the succesful men in their positions.
We, as teachers, can not teach this to students.
I think it is something that they have to learn
themselves and has to be engrained in a man or
he is not going to be a successful practitioner of
medicine.

I have seen this exemplified in following careers
of boys graduating from our own medical school.
Men who are AOA men — in the first ten of the
class, with magnificent scholastic records— who are
not as successful as men in the lower third of the
class, in the practice of medicine. They do not
understand the need and importance of getting
the point of view of their patients and under-
standing their patients and working with their
patients as a team. I wish that we as teachers
would teach the students how to approach the
patient properly and how to express to that pa-
tient sympathy for his troubles and make the
patient feel that there is a “God Love” as Dr.
Watters said, and to make the patient feel that
we are there to help him. You will appreciate
that this is the psychologic, in contradistinction
to the physical care of the sick individual.

Dr. L. Roland Young (Covington) : I feel Dr.

Watters has given helpful ideas in this most im-
portant and interesting phase of medical work.
It was Dr. Wier Mitchell of Philadelphia who was
so strinkingly successful because he treated the
person as well as the disease. This was during
the latter part of the last century and he became
world famed.

This relationship must be as direct and as sim-
ple as possible for best understanding and cooper-
aiton. The objective must be kept clearly befox-e
the mind of the patient and mutual interest
aroused. We must not overlook one important
thing in this matter; it has been shown or proved
that our anticipatory life affects our behavior
more so than does our immediate situation, so
when practical give assurance of recovei-y.

Dr. T. A. Watters (in closing) : I am indeed
pleased with the comments of my discussors. They
are very kind. I wish to re-emphasize the first
interview ; get a wholesome amiable start. I
would like further to i-e-emphasize the importance
of emotions. Really that is what we do with our
patients: we woi-k with their emotions, and the
disorders they produce.

I appreciate Dr. Musser’s remarks. I am in
agreement with him about AOA students. We can
teach a student technics and theories but we can
not supply him with what his home failed to give
in the way of good breeding. I think there is
much the medical student can learn in his home
as far as being a gentleman and handling people
with finesse.

I am glad that Dr. Young agrees with me
about a friendly manner in helping patients being
most important.

I hope in this paper I have brought before you
something which certainly, in my opinion, is timely
and which today cannot be given enough consid-
eration.

0

SYMPOSIUM ON INTENSIVE METH-
ODS OF TREATMENT OF EARLY
SYPHILIS*

THE COMBINED USE OF FEVER AND
CHEMOTHERAPY IN SYPHILIS

TERRENCE E. BILLINGS, M. D.f
Greenwood, Miss.

Probably the first reference to an in-
tensified method of treatment for syphilis
is found in the “Autobiography” of Bene-
venuto Cellini, in which the author refers
in glowing terms to the benefits accruing
to him from an attack of malaria, which,

*Read before the Orleans Parish Medical So-
ciety, February 14, 1944.

tSurgeon, United States Public Health Service.

128

Billings — Symposium — Syphilis

he alleged, cured the Morbus Gallicum that
he had contracted from a serving maid. It
was in the next century that Sydenham
said, “Fever is a mighty engine which na-
ture brings into the world for the conquest
of her enemies.” There was, however, no
application of this idea for the next 200
years.

In 1887, Wagner von Jaurreg published
his first observations relative to the effect
of high temperature on the course of cen-
tral nervous system syphilis. He continued
his work on this phase of treatment for
approximately thirty years, and laid the
foundation for the researches into the ef-.
feet of fever on both T. pallidum and its
hosts, natural and artificial. In the late
1820’s, Bessemans of Belgium began to in-
vestigate the effect of fever on the causa-
tive organism of syphilis, and in 1933 and
succeeding years he published articles in
the American literature, dealing with the
thermal death point of T. pallidum, and the
effect of various types of artificial fever
on laboratory animals and man.

Bessemans’ first report in the American
literature1 was to the effect that high tem-
peratures, whatever the mechanism of in-
duction, killed T. pallidum without serious
injury to the host, and in 1939 he2 published
a study in which he came to the conclusion
that a temperature of 42° C. (107.6°F.)
maintained for one hour, or of 40°C.
(104F.) for two hours, would kill tre-
ponemes in external lesions of primary and
secondary syphilis. This work was done on
rabbits with experimental syphilis, fever
being induced by hot baths or the inducto-
therm, and the results checked as to dis-
appearance of treponemes from the lesions,
healing of lesions, and the results in at-
tempts at transfer to other animals.

Further work, however, by Boak and his
co-workers3 indicated that the thermal
death time for T. pallidum was, in contrast
to Bessemans’ findings, 46°C. (114CF.) for
one hour. In support of this, the data on
fever therapy of early syphilis by Epstein4
in 1935 revealed that of thirty-one patients
with early syphilis treated by fever alone,
10 per cent had clinical recurrences within

a short time, and none became sero-nega-
tive after one or more sessions of fever, up
to 105‘F. of three to six hours’ duration.

A further attempt was made (Boak, Car-
penter, Jones, Kampmeier, McCann, War-
ren and Williams) to treat early syphilis bv
fever alone with prolonged sessions of fever
(9-15 hours) at temperatures ranging from
105-106 F. Eight cases of darkfield posi-
tive, sero-positive, primary and secondary
syphilis were treated. Of this number, five
were followed closely and four underwent
clinical relapse. Of the remainder, all were
found to have remained sero-positive, and
had been placed on chemotherapy by other
physicians or clinics. It was noted, how-
ever, that all cases became darkfield nega-
tive after five hours of fever, and that the
initial lesions healed rapidly. In the follow-
up studies, it was found that all remained
sero-positive, and that some patients dem-
onstrated a nincrease in the titer of their
serologic tests.

Similarly, Simpson, Rose and Kendall3 be-
gan a study, in the course of which they
intended to treat 25 cases of primary and
secondary syphilis by fever alone, given in
10 weekly sessions of five hours each, with
temperatures of 105-106F. They treated
eight patients, but found relapse so fre-
quent that the project was abandoned.

The same workers3 had, since 1932, car-
ried on studies of a combined fever and
chemotherapy schedule in early syphilis, in
which each patient received fever and ar-
senical therapy over 10-20 week periods,
together with an injection of bismuth at
each fever session. This series comprised
27 patients, who received weekly or bi-
weekly fever, together with neoarsphena-
mine and bismuth. Of these patients, fol-
lowed for four or more years, none has
shown evidence of clinical or serologic
relapse.

It is of interest to note that no patients
developed arsenical dermatitis while re-
ceiving this type of combined treatment.
One patient with early syphilis included
in this series had developed exfoliative
dermatitis from neoarsphenamine adminis-
tered prior to his experience with pyreto-

Billings — Symposium — Syphilis

129

chemotherapy. When given a test dose of
1 mg. of the same drug, he again developed
dermatitis, but following recovery from
this episode, was given fever, and while in
the fever cabinet was again given the same
dose of neoarsphenamine. No dermatitis
developed. Additional treatment with bis-
marsen during fever did not produce un-
toward results.

In 1942, the same workers5 published
data on 23 patients treated by a one day
combined pyreto-chemo-therapeutic meth-
od. Each patient received a ten-hour session
of fever, with a temperature of 106°F., re-
ceiving an injection of 0.2 gm. of bismuth
subsalicylate immediately preceding the
fever. An arsenical (mapharsen) was then
given in three 60 mg. doses every three
hours, the first being given at the time a
rectal temperature of 106 °F. was obtained.
Mild jaundice was the only complication of
treatment. All these patients were followed
from six months to two and a half years
before the study was published, and none
developed clinical or serologic relapse in
this period.

The longest series of cases which has ap-
peared in the literature to date is presented
by Bundesen, Bauer, and Kendall.6 These
patients were all treated in the Chicago In-
tensive Treatment Center. The treatment
at present consists of the administration
of 1.76 mg. of mapharsen per kilo of body
weight, with a maximum of 180 mg. re-
gardless of weight, in three equally divided
doses. In addition, 0.26 gm. of bismuth sub-
salicylate is given intramuscularly within
24 hours preceding the beginning of fever.
The arsenical is given according to the plan
originated by Simpson, Rose, and Kendall.
Fever is maintained at 106°F. rectally for
eight hours.

Bre-treatment examination consists of a
complete physical examination with special
attention to the cardiovascular system and
lungs, x-ray examination of the chest, elec-
trocardiogram, lumbar puncture, blood
count, sedimentation time, urinalysis, and
determination of the icterus index.

The total number of patients to date of
publication was 931.

The first 13 patients received treatment
as just outlined, save that the dose of
mapharsen was 120 mg. The thirteenth
case terminated fatally, and, though post-
mortem examination revealed an extensive
miliary tuberculosis, the dose was lowered
to 60 mg. In this case, the calvarium was
not opened at autopsy.

Two-hundred forty-one patients received
60 mg. plus fever, and in this series there
was one death, believed to be due to tuber-
culous meningitis. No postmortem exami-
nation was performed. This type of treat-
ment was presently abandoned because of
the high rate of clinical and serologic re-
lapse— 21.6 per cent.

The dosage of mapharsen was then grad-
ually raised, and 488 patients have now
received fever plus 1.76 mg. of mapharsen
per kilo. Eleven of this series, or 2.25 per
cent have been re-treated because of clini-
cal or serologic relapse.

Of all the cases, 65, or approximately 7
per cent, did not receive the full amount of
fever because of lack of cooperation, or due
to the usual complications of fever therapy.

Of this series, 222 or 23.8 per cent have
become sero-negative, and the serologic
titer of 242 is declining. Unhappily, the
statistical data given are so poorly arranged
and the groups of cases so ill-defined that
it is impossible to arrive at any conclusion
regarding the 488 patients who have re-
ceived what the authors estimate to be the
optimum type of treatment.

Nathaniel Jones of the U. S. Public
Health Service, working in conjunction
with Warren, has been engaged in one-day
treatment at Jacksonville, Florida. Patients
at this facility receive five hours of fever
at 105 °F., with a single dose of 120 mg.
of mapharsen at the close of fever. In re-
spect to this, it is interesting to note that
in Jones’ cases, the persons who received
mapharsen during or before fever had a
high incidence of gastrointestinal and other
reactions. At present, no data have been
published from this source, but results are
said to be promising.

What the future holds for the one-day
treatment of syphilis no one can now pre-

130

Knight — Symposium — Syphilis

diet. It is possible that this method may
afford, in its present form or some modifi-
cation, the Therapia Sterilisans Magna
which is the ultimate goal of all syphilolo-
gists. It may well be that the answer is not
yet. Only time, work, and the scientific
method will allow its evaluation.

REFERENCES

X. Bessemans, A. : New experimental data on artificial
hyperthermia, Ann. Med., 11 :1933, 193S.

2. Bessemans, A. : Experimental contribution to study
of antisyphilitic h.vperthermy produced by physical agents,
Am. J. Syph., Gonor. & Ven. Dis., 22 MTS. 1938.

3. Carpenter, C. M., Boak, It. A., and Warren, S. L. :
The thermal death time of the gonococcus at fever temper-
atures, Am. ,T. Syph.. Gon. & Ven. Dis., 22 :279, 1938.

4. Epstein, N. N., and Cohen, M. : Effects of hyper-
pyrexia produced by. radiant heat in early syphilis, with
description of simple method of producing hyperpyrexia,
J. A. M. A., 104 :S83. 1935.

5. Simpson, W. M., Kendell, II. W., and Rose, D. L. :
The treatment of syphilis with artificial fever, combined
with chemotherapy. Supplement 16, Ven. Dis. Information.

6. Bundesen, II. N., Bauer, T. .T., and Kendell, H. W. :
Intensive treatment of gonorrhea and syphilis; organiza-
tion. objectives, activities and accomplishments of Chicago
Intensive Treatment Center; preliminary report, J. A.
M. A„ 123:816, 1943.

O

THE PRESENT STATUS OF THE FIVE
DAY INTENSIVE TREATMENT
OF SYPHILIS

HARRY C. KNIGHT, M. D.

New Orleans

The intensive treatment of syphilis, no
longer an experiment but now a definite
therapeutic technic, has shaped itself into
two programs: a short, supervised method
of intensive treatment which includes the
various technics requiring hospitalization
and close supervision during the treatment,
and a longer ambulant method in which a
tri-weekly dosage of mapharsen is given
over a period of eight to ten weeks. The one
day type of supervised intensive treatment
is to be discussed in a separate paper this
evening, and the ambulatory method of in-
tensive treatment, sometimes known as the
Eagle treatment, will also be discussed sep-
arately.

This paper deals with the five day prin-
ciple of supervised intensive treatment, into
which must be grouped all of the other in-
tensive methods of therapy not included in
the other two papers. These methods em-
body relatively the same general principles,

although they may differ in the actual tech-
nic of administration.

It is conceded that in the intensive treat-
ment of syphilis by any method, it is neces-
sary to administer at least 1,200 mg. of
mapharsen within the given treatment.
Eagle has shown that the shorter the treat-
ment period, the lower the dosage of ma-
pharsen necessary, and the longer the
treatment period, the greater the dosage
of mapharsen, within a range of 1200 mg.
to 1800 mg. It is also recognized that the
efficacy of intensive treatment by any
method is greatly enhanced by the addition
of bismuth. Differences in treatment,
therefore, depend not upon the dosage or
the drug used, but upon the method selected
for its administration and the convenience
and safety of that method.

At the present time, the short form of
intensive treatment, aside from the one-
day treatment, to be alluded to here as the
five day treatment, includes four separate
technics. First, there is the slow continu-
ous drip technic as described by the New
York group, consisting of the administra-
tion of 240 mg. of mapharsen daily for five
days, each daily dose being in 2,400 c. c. of
5 per cent glucose and given at the rate of
20 mg. per hour for 12 hours.

Second, a rapid drip modification has
been developed in Detroit which consists of
the administration of 1.2 mg. of mapharsen
per pound of body weight, up to a maximum
dose of 180 mg. dissolved in 1,000 c. c. of
5 per cent glucose solution administered in-
travenously in 60-75 minutes and repeated
daily for five days. The total dosage by
this method will be observed to be consid-
erably less than the standard of 1,200 mg.,
amounting actually to 750-900 mg.

A third method of intensive treatment is
the multiple injection method which consists
of giving 60 to 100 mg. of mapharsen dis-
solved in 10 c. c. of distilled water once or
twice daily and repeating this dosage daily
until a total of 1,200 mg. has been given.
This treatment lasts from six to 12 days,
depending upon the dosage and the number
of injections which may be given daily.

The Miami Valley Hospital group in Day-

Kn ig h t — Symposium — Syphilis

131

ton, Ohio, has added fever therapy to the
multiple syringe method with the duration
of the treatment varying from ten to twenty
days.

It is not the purpose of this paper to dis-
cuss the technic of these different methods
in any detail. Some discussion of the in-
dividual comparative treatment results
should be made, however. There is not suf-
ficient evidence in the literature regarding
the combination of multiple syringe technics
with fever therapy to evaluate it adequately
and I have had no personal experience with
it. Since the multiple syringe treatment has
been shown to have a rather higher inci-
dence of complications than other means
of intensive treatment therapy, we have not
considered its use indicated in combination
with fever therapy, although facilities for
that method have been available at the Ma-
rine Hospital. The fact that fever therapy
unquestionably increases the therapeutic
efficiency of some drugs, including maphar-
sen, would indicate that if this combination
does not also produce a higher number of
toxic reactions, it might be a desirable
method. Reports on the multiple syringe
technic indicate that the incidence of re-
actions is at least as high, and probably
higher, than with the slow drip administra-
tion as used by the New York group.

The rapid drip method as used by the
Detroit group and the slow continuous drip
are the two acceptable methods of short in-
tensive administration which we can seri-
ously consider. A comparison of the two
methods shows that the rapid drip, because
of its lower total dosage, had less reactions.
The expected failure rate by the treatment
for all kinds of syphilis was 18.3 per cent
against the expected failure rate by the
slow continuous drip of 13.9 per cent. The
chief difference in the two failure rates lay
in secondary syphilis, in which the rapid
drip showed an expected failure rate of 27
per cent against a failure rate of 17.4 per
cent with the slow drip. Primary syphilis
also showed a higher failure rate. The rel-
atively short series of cases presented by
the proponents of the rapid drip method
makes their low incidence of serious com-

plications open to some question, since one
or two cases would change their figures ap-
preciably. Actually, there is not a great
deal of difference between the two methods
of treatment, except in the results of sec-
ondary syphilis, in which the beneficial ef-
fects of the higher dosage by the slow drip
are notable.

Sixteen hundred patients receiving one
of the two five day drip methods of treat-
ment were reviewed by Elliott and his as-
sociates in June, 1941. The following es-
sential facts should be emphasized from the
large amount of statistical data presented.

The reactions to treatment: five treat-
ment deaths were reported in the series, or
.3 per cent. That is, one patient in 320
cases died as a result of the treatment.
Death was due to hemorrhagic encephalitis
from the clinical picture. Autopsy on three
of the cases showed those changes consistent
with cerebral anoxia, but failed to confirm
the impression of hemorrhagic encephalitis
or to reveal any definite findings which
would permit a pathologic diagnosis.

The most common complaints and reac-
tions in order of their frequency were:
nausea, 60 per cent; primary fever, 48 per
cent; secondary fever, 41 per cent; pain in
arm, 41 per cent; cerebral symptoms (main-
ly headache), 31 per cent; toxicodermas, 11
per cent.

There was an extremely low incidence of
renal and liver irritation or impairment
of function, and of peripheral neuritis.
Only two cases of clinical jaundice were
seen in the series of 1,600 cases. The peri-
pheral neuritis was transient and mild.
There was complete absence of exfoliative
dermatitis, blood dyscrasias and nitratoid
reactions.

A great deal of emphasis has been placed
upon deaths due to this form of treatment
without recognizing the fact that a careful
analysis of large series of cases has shown
that deaths occur from the standard meth-
od of treating patients for a year to 18
months far more frequently than realized.
Cole reported approximately one death in
300 completely treated patients. Other sim-
ilar reports have appeared. It is notable

132

Knight — Symposium — Syphilis

that unpublished information in some of the
treatment centers now using the slow intra-
venous drip method has shown that some
series of cases as high as 500 have been run
without fatalities. It is believed that this
is due to more experience in observing the
premonitory signs which herald a develop-
ment of such complications and that under
careful supervision the death rate can be
kept extremely low. There is no question
but that the incidence of toxic encephalitis
is higher with this method of treatment,
but with experienced supervision the dan-
gers of these complications can be elimi-
nated. In our series of 57 cases at the
Marine Hospital one man developed enceph-
alitis with five convulsions, and with re-
covery in three days. Serious cerebral
symptoms developed in one other patient,
but the treatment was discontinued and he
developed no convulsions and recovered un-
eventfully. The percentage of other toxic
reactions was approximately the same as in
Elliott’s series. There were no cases of
jaundice, one patient developed mild inter-
current pneumonia on the third day, but
completed his treatment while receiving
treatment for pneumonia. We found that
with careful supervision the treatment
could be given to almost all patients, with
primary, secondary and early latent syph-
ilis, and that serious reactions requiring
discontinuance could be expected in about
2-4 per cent of the patients treated. It is
my personal impression that to a great ex-
tent whether or not these serious reactions
terminate fatally depends upon the amount
of supervision the treatments receive. Our
only reason for discontinuing this method of
therapy was shortage of hospital personnel
adequately to supervise the treatments.

The percentage of failures is 13 to 18
per cent in all patients treated. The sero-
logic reversal in patients treated in this
way may not take place for six months after
the termination of the treatment. There-
fore all patients must be closely followed
in order to be pronounced cured.

The greatest value of intensive treat-
ment lies in the number of patients who can
receive adequate treatment. Some method

of case follow-up and case holding is neces-
sary in both intensive and routine anti-
syphilitic treatment. The follow up in the
intensive cases is on adequately treated pa-
tients, while the follow up in the standard
method of treatment is a method of case
holding to keep the patient coming back to
the clinic for a year and a half. The num-
ber of lost patients in the average treatment
clinic using the standard method ranges
from 40 to 75 per cent, in spite of the most
elaborately organized and expensive follow
up methods, complete with police enforce-
ment and all the furnishings of an extensive
epidemiologic routine. This means that
adequate treatment is furnished to only 25
to 60 per cent of clinic patients, depending
on the efficacy of the follow-up method.
Relatively the same percentage of cures is
obtained by the standard treatment method
in the small number of patients adequately
treated. By the use of the five day treat-
ment it is possible to treat approximately
100 per cent of the patients diagnosed and
to assure cures to 85 per cent of the pa-
tients treated. Subsequent treatment im-
proves the prognosis in the resistant cases.
The argument that this treatment is ex-
pensive and requires elaborate hospitaliza-
tion facilities is not valid, in view of the
cumbersome social service and case worker
follow-up method frequently backed up by
police enforcement which is necessary in or-
der to effect adequate treatment to half the
number of patients by standard methods. In
dealing with a disease presenting the mor-
bidity and mortality characterized by syph-
ilis, a death rate of one in 320, or probably
much less, should not deter the physician
from assuring his patients and society the
maximum of protection, particularly when
it is apparent that experience and trained
supervision can reduce this death rate ma-
terially.

It should be emphasized that there is no
controversy between the short form of in-
tensive therapy as embodied in the five day
method and the Eagle treatment consisting
of tri-weekly injections. Surveys of large
series of patients indicate that the per-
centage of results is essentially the same.

Agee — Symposium — Syphilis

133

It is without question that serious reactions
are somewhat less by the longer form of in-
tensive treatment.

The choice of treatment depends on the
factors of social economics, exigency, and
case holding. If the clinic population is
transient or case holding methods are not
satisfactory or difficult to enforce because
of the improvident and unreliable character
of the clinic population, then the shorter
form of intensive therapy is desirable.
When the questions of housing and care for
eight to ten weeks are not significant or
the type of patient is such that case holding
for eight to ten weeks can approach 100 per
cent, then the longer form of intensive treat-
ment is preferable. In private practice, the
longer intensive treatment is obviously most
satisfactory.

o

THE TREATMENT OF EARLY SYPHI-
LIS BY MEANS OF EIGHT WEEKS’
MAPHARSEN THERAPY WITH
BISMUTH

EXPERIMENTAL BACKGROUND AND
APPLICATION IN PRACTICE

OWEN F. AGEE, M. D.f
New Orleans

Dr. Harry Eagle is responsible for the
experimental work on which the tri-weekly
schedule for mapharsen was based. Follow-
ing the publication of reports on extremely
short schedules for treating syphilis in man
with massive arsenotherapy, it seemed im-
portant to find out on experimental animals
the tolerance to certain schedules of treat-
ment and the curative effect of such sched-
ules on animals infected with syphilis.

Chinchilla rabbits were chosen for the
experimental work, weighing 2.1 to 2.9 kg.
and four to six months old. Two strains
were used.

It was found that with respect to excre-
tion, 50 per cent of the sublethal (or maxi-
mum tolerated dose) was excreted in 48
hours ; over 65 per cent was excreted in
seven days. The following figures show

fChief, Section of Venereal Disease Control,
Louisiana State Department of Health.

the findings with respect to tolerance of
mapharsen :

10 mg. per kilo once weekly — tolerated.

10 mg. per kilo three times weekly — all
died.

8 mg. per kilo three times weekly — tol-
erated six weeks.

Then 6.5 mg. per kilo three times weekly
— tolerated six weeks.

It was found that the total amount could
be increased by prolongation of a treatment
schedule, but succeeding tolerated doses
were smaller.

With respect to daily injections, the fol-
lowing data were obtained with respect to
maximum tolerated dose :

4 mg. daily per kilo — four weeks.

5 mg. daily per kilo — two weeks.

4 mg. per kilo four times daily — one day.

2.4 mg. per kilo four times daily — four
days.

These figures boiled down to this :

Daily injections permitted in four days,
31 mg. per kilo, while daily injections for a
period of two weeks permitted only 65 mg.
(compare with 10 mg. at one single dose).

It will be noted that 2.4 mg. four times
'daily for four days would amount to 38.4
mg. per kilo, at an average of one-quarter
amount each time compared with the single
tolerated dose of 10 mg. per kilo. Other in-
vestigators have determined that the toler-
ated dose per kilo for dogs was about the
same as for rabbits. Man presumably is
somewhat similar in this respect. (It
should be borne in mind that the maximum
tolerated dose killed no more than five per
cent of the experimental animals — hardly a
safe margin for human consumption.)

It was found that the maximum tolerated
dose for continuous intravenous drip was
19 mg. per kilo compared with 10 mg. for
a single intravenous dose. Repeated for
four days it allowed a total of 45 mg. per
kilo compared with the four doses daily for
a total of 38.4 mg. per kilo. It is figured
that the cumulative toxicity probably is
somewhat counterbalanced by continued ex-
cretion.

The curative dose was determined by
transfer of lymph nodes of infected rabbits

134

Agee — Symposium — Syphilis

six months after treatment. The following
is the total curative doses on various sched-
ules :

6.3 mg. per kilo for a single injection.

8.1 mg. per kilo for six weekly injections
(six weeks).

7.7 mg. per kilo for 12 tri-weekly injec-
tions (four weeks).

As to daily injections:

6.1 — 3.0 — 6.4 mg. per kilo for one, four,
12 days, respectively.

5.9 — 6.2 — 3.6 mg. per kilo for one, two,
four days respectively for multiple injec-
tions.

8.9 — 6.8 — 11.2 mg. per kilo for one, two,
four days respectively, with intravenous
drip.

Excluding the rather freakish four-day
daily dose and multiple dose, and the con-
tinuous drip, the amount varied only from
5.9 to 8.1 mg. per kilo in time from 10 sec-
onds to six weeks !

The margin of safety is expressed as the
ratio between the maximum tolerated dose
and the minimum curative dose. On any
schedule, any desired margin of safety
could be arrived at by lengthening (or
shortening) the schedule and accordingly
adjusting the dosage. Theoretically if the
doses are as long as a week apart, some
treponemes would propagate.

Many different schemes could be worked
out showing varying margins of safety.

The following table shows the margin of
safety for some typical schedules:

early syphilis in man, the dose of maphar-
sen which has “cured” a satisfactory pro-
portion of patients has been largely inde-
pendent of the frequency of injection or
the duration of treatment. This curative
dose has been 20 to 30 mg. per kg., or ap-
proximately 1,500 mg. in a man weighing
60 kg.

2. The margin of safety provided by any
intensive procedure is therefore primarily
a function of its toxicity. That margin of
safety, calculated from the animal data on
toxicity, has varied from three to 10 in the
treatment schedules which have been used
in man. The observed incidence of toxic
reactions and of deaths has been in com-
plete accord with, and predictable from,
this calculated margin. Thus, the adminis-
tration of 1,200 mg. in a five-day intra-
venous drip, with a safety factor of 3.0, has
resulted in a mortality of 1 :200, and seri-
ous toxic reactions in one in every 100 pa-
tients treated. Standard weekly practice,
with a safety factor of 10, has a mortality
of less than 1 :3,000 ; and treatment sched-
ules with intermediate factors of safety
have resulted in a correspondingly inter-
mediate incidence of toxic reactions and
deaths.

3. It is estimated that a margin of safety
of six to eight is necessary to reduce the
mortality of antisyphilitic treatment to less
than 1 :1,000. With the drugs and methods
now available, no treatment schedule com-
pleted in 20 days or less meets that reason-

TABLE 1.

DEGREE TO WHICH ANTI SYPHILITIC TREATMENT CAN BE INTENSIFIED IN RABBITS WITHOUT

AFFECTING THE MARGIN OF SAFETY

Approximate

amount of treatment which will give

desired margin of

safety for various

Desired

schedules of treatment

margin

Weekly

Tri-weekly

Daily

Injections repeated Intravenous drip

of safety

injections

injections

injections

4 times daily

( 6 hours daily)

10

8 weeks, 8x1.0

3 weeks, 9x0.8

2 weeks, 12x0.5

4 days, 16x0.24

17 days, 17x0.7

mg. per kg.

mg. per kg.

mg. per kg.

mg. per kg.

mg. per kg.

8

7 weeks, 7x1.2

16 days, 7x1.1

5 days, 5x0.8

3 days, 12x0.4

12 days, 12x1

mg. per kg.

mg. per kg.

mg. per kg.

mg. per kg.

mg. per kg.

6

5 weeks, 5x1.6

12 days, 5x1.5

3 days, 3x1.3

2 days, 8x0.6

8 days, 8x1.5

mg. per kg.

mg. per kg.

mg. per kg.

mg. per kg.

mg. per kg.

4

3 weeks, 3x2.5

8 days, 4x1.9

2 days, 2x2.4

1 V2 days, 6x1

4 days, 4x2.9

2

mg. per kg.

mg. per kg.

mg. per kg.

mg. per kg.

mg. per kg.
1 day, 1x9.0
mg. per kg.

COMMENT

able requirement, no matter how the injec-

1. In

the various

intensive schedules tions are

given. That margin of safety

which have been used for the treatment of would, however, be provided by giving the

Agee — Symposium — Syphilis

135

total curative dose in tri-weekly injections
for seven weeks, daily injections for ap-
proximately six weeks, or multiple daily in-
jections, or an intravenous drip for an es-
timated period of four to six weeks.

4. The tri-weekly schedule has the im-
portant advantage of permitting treatment
to be carried out on an ambulant basis in
the average clinic. This method is now un-
‘der study in 80 cooperating clinics. The
size of the individual dose has been fixed
at approximately 1 mg. per kg., with a max-
imum of 80 mg. and a minimum of 40 mg.
The duration of treatment has been varied
from six to 12 weeks. The minimum effec-
tive total dosage, the advisability of giving
concurrent injections of bismuth, and the
applicability of the procedure to the treat-
ment of latent syphilis are some of the fac-
tors which have been considered. Subse-
quently it was found that over the coopera-
tive clinics as a whole, patients receiving
only mapharsen had 12 per cent failures
compared with 1.5 per cent in those who
had mapharsen and bismuth. This includes
all types of early syphilis and considers all
types of failures such as relapses, sero-
lapses, and persistent positives.

In the New Orleans Clinic we used ap-
proximately 1 mg. per kilo per dose for 24
doses given three times weekly for eight
weeks. The dose varied from 40 to 80 mg.,
depending on weight. Eight injections of
bismuth subsalicylate, 0.2 gm. each, were
given concurrently, being given at every
third injection of mapharsen. This sched-
ule of treatment has been used since March.
1942. The data given do not include all
who have been accepted for treatment or
all who have finished. They do include all
patients taken consecutively who finished
or should have finished treatment by June
1, 1943. Naturally the figures on observa-
tion of these cases has continued and is up
to date as of February 1, 1944.

Table 2 shows the color and sex distribu-
tion of patients, and is self-explanatory:

TABLE 2.

Male Female Total

White 17 15 32

Colored 77 51 128

Total 94 66 160

Table 3 shows the diagnosis and the dis-
tribution according to sex:

TABLE 3.

Male

Female

Total

Primary

... 52

12

64

Secondary

.... 36

52

,88

Infectious Relapse ...

... 6

Q

8

Total

... 94

66

160

All of these patients had positive dark
field examinations.

It is noted that the males with pri-
maries outnumbered the females 52 to 12,
whereas the females with secondaries out-
numbered the males 52 to 36. No doubt
this is what one would expect, since the
females would quite likely overlook the pri-
maries. It may not be significant, but one
can speculate that having overlooked the
primaries, the females would go to sec-
ondaries before being recognized more of-
ten than would males, as witness the great-
er number of females with secondaries in
this series. There were six males and two
females with relapses when admitted. Could
this greater number in the male be due to
the probability that less men than women
have already had secondaries before treat-
ment was begun originally?

Table 4 shows the number in each sex
who finished treatment, and the percentage
of each :

TABLE 4.

Number
who began

Treatment Number who finished treatment

94

S

D

66

a

4-*

O

160

4->

G

<U

<u

o>

73

£

4-3

c

o

o

C3

4-3

G

a>

o

p-l

<v

£

a;

a>

4-3

o

33

pLn

Ph

Ph

H

Ph

59.57

49

74.24

105

65.62

It should be mentioned that seven males
were inducted into the Army, and therefore
could not be expected to count at all in the
series showing what should normally be ex-
pected of their attendance. As a rule, such
inductions were done before we were noti-
fied by the patients that they were pend-
ing. This does not mean that no further
treatment was done. It merely means that
we could not be further responsible for the
schedule. It will be noted that 49 of the
66 females, or 74.24 per cent, finished;
whereas only 56 of the 94 males (59.57 per
cent) finished. Eliminating the inductees

136

Agee — Symposium — Syphilis

(a condition peculiar to males only) one
would have 56 of 87 finishing, or 64.36 per
cent.

Table 5 shows the time required for the
patient to finish the prescribed eight weeks’
treatment :

CD

TAB!

CD

cd

,E 5

<D

c3

CD

O

05

CD

CD

£3

%-t

.w

a>

04

a>

O

Q4

s

CL,

H

Cl,

8 weeks ...

18

32.14

19

38.78

37

35.23

9 — 16 weeks

30

53.57

25

51.02

55

52.38

17 + weeks ..

(8

14.29

5

10.20

13

12.38)

Total

56

100.00

49

100.00

105

100.00

It has been arbitrarily divided into three
classifications. While there is no exact way
of evaluating the efficacy of treatment
stretched out over as much as twice the de-
sired time, it seems that the results might
reasonably approach the approved eight
weeks’ schedule and it would seem that
treatment requiring over sixteen weeks is
not sufficiently accelerated to be called in-
tensive treatment.

It will be noted that of the 56 males who
received 24 mapharsen and eight bismuth
injections, 32.14 per cent finished in the
eight week’s time ; of the 49 female patients
who finished treatment, 38.78 per cent did
so in the prescribed time. Combining the
sexes, 35.23 per cent finished in eight
weeks. Of the males, 53.57 per cent, and
of the females, 51.02 per cent finished
treatment from nine to 16 weeks inclusive.
A total of 55 males and females finished
in the nine to IS week group, representing
52.38 per cent of those who finished. Com-
bining the two foregoing groups, 92 pa-
tients finished treatment within a reason-
ably intensive schedule, representing 87.62
per cent of those who finished and 57.50
per cent of all those who began treatment.

Of the 55 who never finished treatment,
20 had less than 7 doses of mapharsen ;
18 had from seven to 12 doses; 16 had from
13 to 18 doses; and one had from 19 to 23
doses.

Of the 48 males who completed treatment
in 16 weeks or less and who had positive
Kahns at the beginning, varying from four
to 400, 23 had a reduction at the end of
treatment and 22 had negative Kahns at

the end. Of the 44 females who finished
and who had been positive, 26 had a reduc-
tion in titre and 17 had negatives. The
titres were essentially similar at the begin-
ning, so far as was noted. Fifteen of the
22 males who had a reduction in titre at
the end had further reduction during obser-
vation (four were not followed further).
Twelve of the 20 females with a reduction
in titre had still further reduction during
observation, (three not followed). One
male relapsed (had a recurrence), 1.9 per
cent. His lesion was negative on darkfield
examination, but his Kahn titre rose to 40
at the time. Originally his diagnosis had
been seronegative primary. He had had
three negative bloods and a negative lum-
bar puncture during the period of obser-
vation. There were two infectious relapses,
4.5 per cent (in females) both with posi-
tive darkfields and increased Kahn titres.
One had had no follow-up, the other had
ended treatment with a quantitative Kahn
of 4, subsequently it was negative. They
could have been considered either reinfec-
tions or relapses. The diagnosis had been
secondary syphilis in each case, primarily.
The elapsed time since cessation of treat-
ment was seven and 11 months, respective-
ly. One had an ulcer of the cervix, the oth-
er mucous patches of the vagina, as “re-
currences.” There were two each with
serolapses only, in each sex. There was one
of each with no reduction in titre through-
out treatment or observation. Two males
who finished treatment were seronegative
throughout treatment and observation.

Table 6 shows the per cent of patients
who had reactions, and some who we judge
could not be further treated with such
therapy :

TABLE 6.

QJ

03

S

Mild reaction 7

Severe reaction 1

Stopped because of
reaction* 1

O)

o

2 c

a)

O £

o

-t-> CD
CD CD

as

4J <D

a

03 -

s

03 s.

« a

O)

£

A 3

PC a

o

cS-S

7.44

15

22.73

22

13.75

1.07

14

21.2

15

9.37

1.07

6

9.09

7

4.37

* Reactions based on the total number of pa-
tients placed on this treatment, and not on the
number who completed it.

Agee — Symposium — Syphilis

137

Of this group, 4 females finished treat-
ment with moderate decrease in dosage of
mapharsen.

Table 7 shows the distribution of patients
who finished despite reactions:

TABLE 7.

Male Female Total

Finished treatment with:

Mild reaction 4 14 18

Severe reactions 0 4 4

The mild reactions were as follows:

For the males : Three, nausea (one also
had bleeding gums) ; four, nausea and vom-
iting.

For the females: Six, nausea (one with
diarrhea) ; four, nausea and vomiting; two,
chills and fever; one, pain in legs; one, re-
tinitis with brick-dust opacities of vitreous
of the right eye with failing vision. History
of previous eye complaint of similar na-
ture. Ophthalmologist thought not due to
syphilis nor to treatment ; one, diarrhea and
edema of ankles.

Of the severe reactions: One male with
icterus, chills and fever ; eight females with
severe nausea and vomiting (one with
chills) ; three with icterus; one with blood
dyscrasia, R. B. C. 2.5 million, W. B. C.
2200 following fever and moderate shock.
Marked icterus, later ; one with nausea and
vomiting, later tolerated neosalvarsan.

Most of the reactions of any consequence
occurred during the second and third week
(fourth to tenth dose).

There were no deaths.

The follow-up (observation) of the 76
patients who finished treatment, and who
were observed later, was as follows :

7 followed for 1 month

8 followed for 2 months

9 followed for 4 months
6 followed for 5 months

5 followed for 6 months

6 followed for 7 months
5 followed for 8 months
8 followed for 9 months
4 followed for 10 months
3 followed for 11 months

1 each followed for 12, 13, 14, and
17 months.

On an average, .the 76 patients followed
were observed for almost six months. Six-

teen were not observed after finishing
treatment.

Thirty-one patients had lumbar punc-
tures during observation. All were nega-
tive. These lumbar punctures are sched-
uled at the third month in order to get them
while the patients are still available, if pos-
sible. Some were done as late as nine
months.

SUMMARY

There were no deaths among the 92 pa-
tients out of 160 who began intensive
(Eagle) schedule fixed at approximately 1
mg. per kilo three times weekly, but extend-
ed in time (not amount) by 55 of them to
as much as nine to 16 weeks inclusive. The
period of observation following treatment
averaged approximately six months. Spinal
fluids were negative on the 31 examined.
Two females had infectious relapses (un-
less one should consider them reinfections) .
One male had a clinical relapse not proved
by darkfield. There were two with serore-
lapses only, one of each sex. Altogether,
seven of the 92, or 7.6 per cent could be
considered treatment failures with the
schedule indicated, considering the fixed
positives, the serolapses, and the probable
infectious relapses. If the three recur-
rences should be considered as reinfections
or unproved relapse, as the case may be,
there still would be four treatment failures,
or 4.35 per cent.

REFERENCES

1. Eagle, H., and Hogan, R. B. : An experimental evalu-
ation of intensive methods for the treatment of early
syphilis. I. Toxicity and excretion, Ven. Dis. Inform.,
24 :33, 1943.

2. Eagle, H., and Hogan, R. B. : An experimental evalu-
ation of intensive methods for the treatment of early
syphilis. II. Therapeutic efficacy and margin of safety,
Ven. Dis. Inform., 24 :69, 1943.

3. Eagle, H., and Hogan, R. B. : An experimental evalu-
ation of intensive methods for the treatment of early
syphilis. III. Clinical implications, Ven. Dis. Inform.,
24 :159, 1943.

DISCUSSION

Dr. M. T. Van Studdiford (New Orleans) : I
think such timely discussions as the papers of Drs.
Billings, Knight, and Agee call for praise because
of their conservatism at a time when so many read
the Reader’s Digest “One Day Cure.”

In considering a standpoint for treatment we
must consider the objectives: Public Health Agen-
cies wish to stop the spread of syphilis — that is
kill the family tree while it is a chancre now.

138

Agee — Symposium — Syphilis

The Army, Navy and maritime agencies want to
put man-power back at work; the private practi-
tioner wishes to cure his patients as quickly as it
can be safely done.

Dr. Politzer, years ago, tried multiple injections
with neosalvarsan but reactions were too frequent.
So years passed before his group began to use
the less toxic arsenoxide. When one thinks of
the arsenicals in a comparative way, old salvarsan
“606” would compare to 100 proof straight whisky;
neosalvarsan to 90 proof whisky in a highball, and
mapharsen, phenarsine or any of the other ar-
senoxides as Scotch whisky highballs. We see
that the strongest gives the biggest headache and
so forth. All have their places in therapy but
must be used knowingly. If one treats syphilis
in its early stages and with a rapid method it
has been shown here that a total of 1200 to 1400
mg. of arsenoxide should be administered. This
can be done with the Schoch-Alexander seven day
method, the modified Eagle-Hogan method for
eight weeks, or the fever-arsenoxide one day
method.

All can be given in most instances, so few pa-
tients in each series have been treated that one
or two deaths or a few reactions cause large
changes in the percentages but as more and more
series are added from other clinics we can then be
able to evaluate results and arrive at a quicker,
safe method more up to date. Probably the twice
a week arsenical and one bismuth injection for
the ambulatory worker or the three a week arseni-
cal and one bismuth injection for the hospitalized
patient appears to me to be safe, conservative yet
fast enough to cover the desires of all groups. I
think the above papers tend to bear out the opin-
ion that we have gone a long way in our advances
in therapy.

Dr. V. Medd Henington (New Orleans) : The
papers that have been presented tonight have cov-
ered the subject of “Intensive Treatment of
Syphilis” so well that there is little room for dis-
cussion. However, there are a few points I would
like to bring up for your consideration: First, we
must remember and always be conscious of the
fact that the drugs used in syphilis are of such
a character that to treat the disease effectively
makes a certain minimum risk inevitable. We must
also remember that it is not always possible to
apply animal experimentation directly to clinical
usage, for experimental animals do not develop
optic atrophy, exfoliative dermatitis, or toxic
hepatitis, which are among the most serious reac-
tions observed in human subjects.

The rapid or intensive treatment of syphilis is
not something that has sprung up in the past few
years, although it was as we might say popularized
by Chargin, Hyman and others in 1934. For the
rapid treatment of syphilis is as old as the
arsphenamines for was it not Ehrlich’s dream to

cure the disease with one injection or, as he ealled
it, the magic bullet.

As early as 1910 Hoffmann attempted a three
day cure of syphilis by the daily simultaneous in-
travenous and intramuscular administration of
arsphenamine.

Mapharsen, too, is not new in the treatment of
syphilis for it was first discovered by Ehrlich who
discarded it because of its supposed toxicity. How-
ever, more recently it was revived by Tatum and
Cooper. Mapharsen has gained much popularity
in the past few years for since the action of the
arsphenamine is now rather definitely proved to be
due to the formation of arsenoxide in the body, it
is only logical to believe that direct administra-
tion of arsenoxide would have definite advantages.
Since only part of the arsphenamine injected is
converted into arsenoxide in the body, the balance
must be excreted in the form of various arseni-
cal compounds. This excess arsenic may be one
of the causes of untoward reactions. We know
that arsphenamine “606” is excreted primarily in
the feces and that neoarsphenamine is excreted
primarily in the urine. I am not familiar with
the primary route of excretion of mapharsen and
perhaps this is one question that can be answered
later in the discussion by Dr. Agee.

I noticed that Dr. Agee makes the statement
that no treatment schedule completed in 20 days
or less meets the safety factor of 10 or in other
words a mortality factor of less than 1-3000.

If I may be allowed to bring personal experi-
ence into the discussion I should like to tell you
about some of the work that is now being done
at Columbia University. At Columbia we treated
only male patients simply because we were allotted
only one ward in which to carry out our experi-
ment. All patients presented either primary or
secondary lesions with a positive darkfield. These
men were given the original “606”, which is com-
monly known as old arsphenamine. One group
was given four injections daily for six days, mak-
ing a total of 3.6 gm. The other group was given
1 gm. in one intravenous injection every other day
for three days, making a total of 3 gm. The
youngest patient was 15 and the oldest 53 years.
There was not one fatality in 300 cases. Nausea,
vomiting, and transient neuritis were the worst
reactions; there were no cases of exfoliative der-
matitis, liver necrosis or the dreaded hemorrhagic
encephalitis. It was our impression that the fre-
quency of injections and not the total amount of
arsphenamine was important in producing toxic re-
actions. For the patients who received only 3 gm.
of arsphenamine had but three intravenous injec-
tions while the patients who received 3.6 gm. had
a total of 24 injections. Yet the patients receiving
only three injections had many more reactions than
those patients receiving 24 injections and 0.6 gm.
more arsphenamine. It was also interesting to
note that every patient who came in with pri-

Agee — Symposium — Syphilis

139

mary or secondary syphilis had a strongly posi-
tive Ehrlich’s test for urobilinogen in the urine
and practically every patient had a 4 plus cephalin
flocculation. It is further interesting to note that
both of these tests became negative within 24
to 48 hours after treatment was begun.

The eight week treatment as presented tonight
was reported to have a 7.6 per cent failure in 92
cases. Although we must realize that 92 patients
comprise a rather small group I think that the
percentage of failures is very small for, with

the regular 18 month anti-luetic treatment the per-
centage of failure is around 10 per cent.

In conclusion, we can say that the massive
therapy of syphilis is still in the experimental
stage in the sense that it is still too soon to de-
termine the end results of treatment, as well as
all the dangers of the method, which obviously
are greater than those of standard methods of
treatment.

As Goldblatt once said, “Syphilis waits twenty
years to destroy our therapeutic illusions.”

H 'Sk 'S*. 'ft Vi, M T* »• , ^

BUY — -

UNITED STATES WAR
BONDS and STAMPS

140

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THE DOCTOR FIGHTS

On Tuesday evening over the Columbia
Broadcasting Network there is to be heard
a radio program which should be of great
interest to all physicians. The program
that was heard just prior to writing this
editorial was one of the best that we have
heard for a long time. It was dramatic, it
was well sustained, and the actors were vo-
cally splendid. It might well be that some
casual critics will complain that the doc-
tor was almost deified in this program.
To a large extent physicians in general
were held to be professional people of great

unselfishness, marked generosity and un-
failingly courageous, but elsewhere, in va-
rious non-medical publications and in criti-
cal circles, the doctor is often freely
criticized. Even if this program does pos-
sibly put the doctor on a higher plane than
he as an individual thinks he belongs,
nevertheless, it is pleasant and nice to hear
agreeable things spoken about the most un-
selfish and selfless profession in the world
which is often unjustifiably censored.

o

THE DISTRIBUTION OF BHYSICIANS
IN SOUTHEASTERN STATES

A. M. Lassek*, head of the Department
of Anatomy of the Medical College of the
State of South Carolina, has prepared a
statistical report on the distribution of phy-
sicians in Alabama, Arkansas, Florida,
Georgia, Kentucky, Louisiana, Mississippi,
North and South Carolina and Virginia.
This is a most detailed study which will
be buried in a journal of very small cir-
culation so it might be worth while to point
out some of the facts that Dr. Lassek has
obtained from his survey.

The ratio of resident physicians to the
population in the above states is 1:1080,
which is a lower ratio of doctors to the
population than any other section of the
country. Alabama has one doctor for
every 1,334 persons in the state. Other
states have a somewhat lower ratio and
only Louisiana, Tennessee and Virginia, of
the Southern states, have ratios under
1:1000. In seven of the states there are
at present thirteen medical schools on a
four-year basis and three two-year schools.
In 1942 there were slightly over 28,000
physicians who graduated from Southern
schools or, expressed in another way, 15.8
per cent of all the registered doctors in
the United States. Thirty-eight per cent
of the doctors remained within the state
in which the medical school from which
they graduated was located. Twenty-six
per cent located in other Southern states,

*Lassek, A. M.: The role of the Southeastern
schools of medicine in the national distribution of
physicians, J. Assn. Am. Med. Colleges, 19:217,
1944.

Editorials

141

whereas 35 per cent engaged in the prac-
tice of medicine in states not located in
this region. In all, 62 per cent of the
graduates of one or another of the South-
ern schools did not remain in the state
where the school was located.

Tulane, of all the Southern schools, has
the greatest number of living graduates,
3,481 physicians scattered all over the
country. Of these several thousand grad-
uates, approximately one-third remained to
practice in Louisiana, one-third in South-
ern states and one-third elsewhere in this
country. Louisiana State University has
not graduated many students as yet. Near-
ly three-fifths of their graduates have re-
mained in Louisiana, practically 28 per
cent have moved away from the South-
eastern states.

Graduates from schools from the North,
East and West have immigrated to the
South. There are 7,725 doctors who have
moved to the Southeastern states. If the
graduates of Southern schools had not
moved out of the South, and to this group
were added the group from the North, the
ration of physicians to patients would be
1:721.

Distribution of doctors in the Southeast
is considered to be unfavorable and the
reason for this may be attributed properly
to per capita income which is considerably
lower than any other of the six regional
subdivisions of the United States. The
rural population of Louisiana, for example,
does not have a sufficient number of doc-
tors per patient in spite of the fact that in
this state the ratio is much better than it
is in most of the other Southern states.
New Orleans, . on the other hand, has a
very pronounced lowering of physicians to
patients ratio. In this city there is one
doctor to every 417 persons. These figures
are somewhat higher than in other large
cities in the South. Little Rock, for ex-
ample, has one doctor to every 368 persons;
Columbia, S. C., 1 :260. In some of the
states in rural areas the doctor-patient ra-
tio is 1 :2500. In some of the very poor
counties of the South the ratio is as high
as 1 :5000. Definitely the urban population

of the South is well supplied with doctors,
the rural areas poorly supplied. Lassek
points out that legislators have the mis-
guided opinion that if a man graduates
from a state university he will settle in that
state and that the distribution of physi-
cians throughout the state would be such
that all urban, suburban and rural areas
would be well taken care of. This is ab-
solutely incorrect as Lassek points out.
Furthermore, the state that has the best
regional distribution, Florida, has no medi-
cal school. It is amply supplied with doc-
tors, probably because Florida has the larg-
est income per capita of any of the South-
ern states.

o

STUDIES OF HUMAN PLASMA

The entire July issue of the Journal of
Clinical Investigation (vol. 23, July 1944)
is devoted to chemical, clinical and immu-
nologic studies on the products of human
plasma fractionation. These studies were
conducted by a group of scientists at va-
rious laboratories throughout the country
under contract, recommended by the Na-
tional Research Council’s Committee on
Medical Research, between the Office of
Scientific Research and Development and
the particular University laboratory. They
represent a conjoint investigation which
is almost unparalleled in the history of
scientific research.

Many of the studies are of particular in-
terest to the physiologist, biochemist or the
immunologist and for the most part have
but little direct significance to the clinician,
although the whole series taken together
are fundamental in the understanding of
plasma therapy and to the clinician should
be of great value if he wishes to know the
why and the wherefore of many of the
practices carried out in the ordinary art of
medicine. Of course in war surgery the
information already obtained has been of
extreme value to the casualty suffering
from shock or the shock-hemorrhage syn-
drome.

A few of the distinctly clinical observa-
tions might be noted here. The use of
dried albumin is an excellent example.

142

Organization Section

This fraction of the plasma may be ex-
tracted and dried. The amount that may
be used as a temporary expedient repre-
sents an extremely small quantity which
might be carried by any doctor in his emer-
gency kit. A standard package of 25 grams
of albumin diluted to 100 c.c. is equivalent
in its osmotic effect to 500 c.c. of citrated
plasma. There was found to occur prompt
improvement after the injection of this
concentrated albumin into a series of pa-
tients with shock and burns. It is not harm-
ful. The package is compact and available
for immediate and rapid administration.
Furthermore it is stable and pyrogenic re-
actions do not occur. In patients who have
a notable loss of serum albumin as in those
with chronic hypoproteinemia for example,
in nephrosis and in cirrhosis of the liver,
the concentrated albumin may be of great
service in the treatment of these patients.
The albumin therapy increased arterial
pressure and cardiac output in patients suf-
fering from shock. For subsequent treat-
ment where there has been a severe anemia
whole blood should be given when available.

Normal human gamma globulin was
studied as to its antibody content. It was
found that this globulin did contain anti-
bodies reacting to diphtheria toxin, strep-
tococcal toxin, influenza A virus and
mumps virus. These antibodies were con-
centrated from fifteen to thirty times when
compared to pooled plasma. As a matter
of fact the potency of fraction II, which is
the fraction with which these papers are
dealing, is approximately that of conval-
escent serum. As Enders says, the impli-

cations of these findings, in regard to frac-
tion II as an agent in the prophylaxis and
therapy of disease, are great.

Measles is a disease which, in the ordi-
nary healthy child, is of no particular mo-
ment but in certain children convalescent
serum has been used repeatedly to prevent
or modify the course of the disease. Two
groups of independent observers have
found that fraction II definitely modifies
the disease, makes it less severe and in sev-
eral instances prevented the development of
a rash, although Koplik spots were present.
In children exposed to measles it prevented
the development of the disease in 71 per
cent of the cases, whereas amongst the
controlled series 89 per cent developed
measles of average severity.

Fibrin foam, in another series of studies,
was found to be an excellent hemostatic
agent, notably in the control of oozing in
neurosurgery, and also in the prevention of
adhesions between damaged nervous tissue
and adjacent structures. Lastly, another
group of investigators have shown that bo-
vine serum gamma globulin is highly effi-
cient in serum-protein regeneration.

The application of these studies, under-
taken largely as result of war, to civilian
needs is obvious. In the not too near future
it is quite possible that human or bovine
serum gamma albumin will play a most im-
portant part in the armamentarium of the
physician who is treating disease or who is
operating on patients. It can readily be
foreseen that in human serum albumin
there is an extremely potent therapeutic
principle which will advance materially
the satisfactory treatment of patients.

o

ORGANIZATION SECTION

The Executive Committee dedicates this page to the members of the Louisiana
State Medical Society, feeling that a proper discussion of salient issues will contri-
bute to the understanding and fortification of our Society.

An informed profession should be a wise one.

EMERGENCY MATERNAL AND
INFANT CARE PLAN
A great deal of water has run under the
bridge in regard to the EMIC plan since the
meeting of the House of Delegates of the

State Society which was held in April of
this year and it is the thought of the offi-
cers of the organization that it might be a
good idea to acquaint our members with the
present status of the plan as it has been

Organization Section

143

worked out in the state up to date. Imme-
diately following the meeting of our House
jof Delegates our past president. Dr. C. C.
deGravelles, made a trip to Washington for
the purpose of presenting to the sub-com-
mittee on appropriations the brief on this
subject prepared by a special committee
and approved by the House of Delegates.
This brief was published in the organization
section in the June issue of our Journal. Dr.
deGravelles reported that the committee
was very courteous to him and stated that
the manner in which the facts were pre-
sented far surpassed most of the major
pleas made before them by other organiza-
tions and individual physicians and com-
plimented him on the splendid presentation
made by the doctors of Louisiana. As a
whole the committee seemed to look favor-
ably upon the ideas submitted in our brief,
however the final action taken by the Gov-
ernment was to continue operation of the
plan as it had been handled previously, in-
creasing the financial assistance to carry
out the plan, disregarding all objections
raised by Louisiana physicians as well as
other physicians throughout the country.

Attempts have recently been made to
complete a survey of the operation of the
plan in the State of Louisiana including
number of deliveries made by physicians,
indicating number handled under the EMIC
plan. However, due to the fact that the
Maternal Division of the State Health De-
partment has not complied with repeated
requests for such information, we are un-
able to present exact figures at this time.

The Executive Committee of the Orleans
Parish Medical Society and the general
membership of that society approved the
action of the House of Delegates and re-
quested Dr. David E. Brown, Director of
the State Department of Health to do all he
could to aid in the establishment of the
principle of the allotment plan in the han-
dling of these cases. A letter has been re-
ceived from Dr. Brown in which he states :
“I wish to assure you that I shall be glad to
do everything that I can to further the reso-
lution which was adopted at the last meet-
ing of the House of Delegates of the Louis-

iana State Medical Society regarding the
Emergency Maternal and Infant Care Pro-
gram in this state. We agree with you that
if this program was administered directly
with the individual, much more time would
be available for the personnel of our Ma-
ternal and Child Health Section to do gen-
eralized public health work. Therefore, we
shall make every effort to have the allot-
ment payment plan for the maternal and in-
fant welfare program, as approved by the
State Medical Society, put into effect.”

Attention of the Committee on Maternal
Welfare has been called to the fact that
one of the state institutions has been taking
care of some of the EMIC cases. It has
been ruled by the Attorney General of the
State of Illinois that these cases can not be
handled in the State of Illinois by charitable
state institutions. This ruling was based
on the fact that the plan was established in
order to give private care to these patients
as they are not charity cases. The members
of our Committee on Maternal Welfare were
canvassed and it was found that it was the
unanimous opinion of the committee that
charity hospitals in this state should not
participate in this plan for the same reason
as stated in the decision of the Attorney
General of the State of Illinois.

Representative Miller, of Nebraska, has
introduced a bill (H. 4663) in Congress
which approves the transfer of operation
of the Emergency Maternal and Infant Care
Plan from the Children’s Bureau of the
Labor Department to the Public Health
Service. The reason for this suggested
transfer is that the plan involves medical
care and it is therefore felt that it should
be handled and operated by a medical body
and not by a Labor Board which is composed
primarily of labor representatives and so-
cial agencies which are unanimously op-
posed to practically every suggestion offered
by the medical representatives on the com-
mittee of the Labor Department. The mem-
bers of our Committee on Maternal Wel-
fare have approved the suggestion that we
communicate with our representatives and
senators in Washington asking that they
approve this bill, endorsing the removal of

144

Organization Section

the plan from the Labor Department to the
Public Health Department. It is suggested,
therefore, that all members of our organiza-
tion who are interested in this problem
write their representatives asking that they
take an active part in helping to have passed
this proposed legislation.

The East Baton Rouge Parish Medical
Society recently adopted the following reso-
lution : “Whereas, The program now in op-
eration for maternal and infant care for
wives and infants of enlisted men in the
four lower grades is unsatisfactory to the
members of the East Baton Rouge Parish
Medical Society and, in many instances, to
the enlisted men and their families; and,
Whereas, The Emergency Maternity and In-
fant Care Program is a definite form of bu-
reaucratic medicine brought upon the pro-
fession as a war emergency measure during
this period of stress; be it therefore Re-
solved, That the members of the East Ba-
ton Rouge Parish Medical Society with-
draw from participation in the EMIC pro-
gram and be it further Resolved, That, for
the duration of the war, the members of the
East Baton Rouge Parish Medical Society
will render medical services, without re-
muneration, to the wives and infants of en-
listed men in the four lower grades.’’ This
resolution indicates that the plan, as it is
operated at present, is meeting lack of co-
operation of the medical profession of the
state due to the manner in which it is han-
dled by the government. The fact that the
members of the Baton Rouge Society will
handle these cases without remuneration in-
dicates that the medical men of the state are
not looking at the question from a financial
viewpoint and are willing to do their share
without regard to personal interest. These
patients will probably, in this way, be given
better service than if they were handled un-
der the present set-up of the EMIC plan.

Recently a questionnaire was sent to the
entire membership of the Orleans Parish

Medical Society to ascertain how many were
interested in taking care of EMIC patients,
requesting that the form be returned if the
doctor wished to handle these cases. Out of
a membership of more than five hundred
only two responded that they would agree
to cooperate in handling cases under this
plan. This shows again how the medical
profession of the State of Louisiana feels
in regard to this matter.

In the most recent issue of the Western
Journal of Surgery, Obstetrics and Gyne-
cology an editorial appeared in which it
was brought out that Miss Lenroot and her
co-workers are taking entire credit for the
operation of this plan and the ‘service ren-
dered and are giving no credit to the medi-
cal profession for the part they are playing
in the operation of the plan. It is appar-
ent, from such statements, that the medical
profession is not being dealt with fairly by
the Government ; responsibility for the work
being carried on placed on the doctors but
credit given to non-medical groups, which
is evidence of the fact that the plan is just
another step in an attempt toward sociali-
zation of medicine which is being carried
on by the bureaucrats in Washington with-
out the altruistic motive of serving those in
the armed forces of our Country. •

The Maternal Welfare Committee has so-
licited the various Louisiana candidates,
both opposed and unopposed, for election to
the Congress of the United States, asking
their reaction and opinion in regard to the
Wagner - Murray - Dingell Bill, the Miller
Bill, and also the bill regarding deferment
of pre-medical students. All of the replies
received have stated that these candidates
are in favor of all bills which would benefit
the medical profession and are opposed to
those in conflict with the desires of the
medical profession. Those who claimed
they did not have sufficient knowledge to
discuss these issues stated that they will be
open to advice from those who know more
about these matters than themselves by con-
sultation with members of the medical so-
ciety. The reaction of these men shows
that if the medical men would state their

Louisiana State Medical Society News

145

case to the men running- for public office
and get an expression from them before
their election, nearly any honest public of-
ficial will be most willing to cooperate with

us in regard to medical matters when prop-
erly approached.

Edwin L. Zander, M. D., Chairman
Committee on Maternal Welfare

o

LOUISIANA STATE MEDICAL SOCIETY NEWS

CALENDAR

PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS

Society

East Baton Rouge

Morehouse

Orleans

Ouachita

Rapides

Sabine

Second District

Shreveport

Vernon

Date

Second Wednesday of every month
Second Tuesday of every month
Second Monday of every month
First Thursday of every month
First Monday of every month
First Wednesday of every month
Third Thursday of every month
First Tuesday of every month
First Thursday of every month

Place. ,

Baton Rouge
Bastrop
New Orleans
Monroe
Alexandria

Shreveport

NATCHITOCHES PARISH
A meeting for discussion of Senate Bill 1161 was
held for the physicians of Natchitoches Parish in
Natchitoches on the night of August 18. Principle
speakers at this meeting were Dr. David E. Brown,
Director of the Louisiana State Board of Health,
Dr. Walter F. Couvillion, Councilor of the Eighth
District and Dr. P. T. Talbot, Secretary of the
State Society. .

o

AN IMPORTANT SYMPOSIUM
A symposium on the Heart and Circulation will
be held at the Louisiana State University, School
of Medicine, 1542 Tulane Avenue, New Orleans 13,
Louisiana on October 25-27, 1944, from 9:30 a. m.
to 5:00 p. m. each day. Those who are interested
are invited to attend. No fee is charged. The
visiting participants are Dr. Visscher, University
of Minnesota, who will discuss cardiac efficiency
and metabolism; Dr. Isaac Starr, University of
Pennsylvania, who will discuss the ballistocardio-
graph; and Dr. Frank N. Wilson, University of
Michigan, who will speak on electrocardiography.
Other speakers are from Tulane University and
Louisiana State University.

o

BASE HOSPITAL NO. 24
The latest reports from private correspondence
and from the Times Picayune indicate that Base
Hospital No. 24 (Tulane Unit) has been recol-
lected and is now functioning as a unit some 60
miles from Florence. The Unit has been assigned
to a recently completed tuberculosis sanitarium
built by Mussolini for his veterans. It is situated
in the outskirts of a large town and “has all the
comforts and conveniences afforded by Touro or
Charity Hospital.”

While some of the members of the Unit were
stationed in Rome they had the rare privilege of
having an audience with the Pope.

o

DR. C. L. WILLIAMS PROMOTED

Dr. C. L. Williams who has been medical director
of the Southern district of the United States Pub-
lic Health Service has been promoted to the rank
of Assistant Surgeon General and will leave for
Washing-ton the first part of August. Dr. Wil-
liams has been in New Orleans since July, 1940.
During this period of time he has come in con-
tact with many members of the medical profession.
He has been an outstanding help to the state and
city boards of health and he has taken an active
part in many of the civic organizations. The many
friends of Dr. Williams will be glad to hear of his
promotion but sorry to hear he is leaving New
Orleans. In Washington he will be in charge of
the Bureau of State Services.

Dr. Otis L. Anderson is scheduled to succeed Dr.
Williams.

o-

DOZIER HONORED

The many friends of Major Horace B. Dozier,
who graduated from Tulane Medical School in
1939, will be pleased to hear that he has been
decorated again; this time with the Legion of
Merit Award.

o

OFFICE OF COLLECTOR OF INTERNAL
REVENUE

By Public Law 414, 78th Congress, effective July
1, 1944 — the substance “isonipecaine,” commonly
known as “demerol,” and any substance identified
chemically as l-methyl-4-phenyl-piperidine-4-car-
boxylic acid ethyl ester, or any salt thereof, by

146

Louisiana State Medical Society News

whatever trade name designated, have been brought
under provision of the Federal narcotic laws. No
provision is made to exempt preparations in this
category.

Registration: All manufacturers, wholesale and
retail dealers, and practitioners, procuring or pre-
scribing “demerol” must be registered in appropri-
ate class and must submit to Collector on or be-
fore September 1, 1944, on appropriate Form 810-E,
811-C, or 713, an inventory of all stock on hand
July 1, 1944. Any of the above having registered
and secured special tax narcotic stamp for fiscal
year beginning July 1, 1944, will not be required
to re-register for selling, dispensing, or prescribing
“demerol” and its derivatives. However, if such
narcotic preparations were held on July 1, 1944,
and not included in the inventory filed, a supple-
mental inventory will have to be submitted, listing
only stock of demerol and its derivatives on hand
July 1, 1944.

All transactions involving “demerol, etc., must,
therefore, be made pursuant to official narcotic
order forms or prescriptions and must be reported
in monthly narcotic returns in the same manner
as opium, coca leaves, and their derivatives.”

o

NEWS ITEMS

Lt. Col. Ambrose H. Storck addressed the an-
nual meeting of the State Medical Association of
Utah in Salt Lake City on August 25. Colonel
Storck spoke on “Abdominal Wounds; Management
and Results in the Present War.”

o

Announcing that the American people had con-
tributed an all-time record of $10,973,491 to the
1944 Fund-Raising Appeal of The National Foun-
dation for Infantile Paralysis, Basil O’Connor,
Foundation president, declared last night that these
donations will permit an expansion of the war
against the children’s enemy on the home front.

With epidemics or serious outbreaks now taking
their toll in twelve of the states of the nation, Mr.
O’Connor pointed out that the number of cases
reported is already higher than for the comparable
period last year when the country suffered its
third worst epidemic.

In the first 31 weeks of 1944, the United States
has had more cases of infantile paralysis reported
than at any comparable time shown on the records
in 28 years, The National Foundation for Infantile
Paralysis declared today.

Latest figures from the U. S. Public Health
Service, showing state reports through August 5,
reveal a total of 3,992 cases, the National Foun-
dation said. This is 1,226 cases more than re-
ported for the same period last year when the
nation suffered its third worst polio epidemic, and
1,089 cases more than in 1931 when the second
worst outbreak was x-ecorded. The records of the

worst outbreak in 1916 show there were 6,767
cases by August 1 of that year.

In five states where the outbreaks are in epi-
demic or near-epidemic proportions, the total cases
reported through August 5, 1944, are higher than
those states reported for the entire year of 1943.

They are:

Through

Entire

Aug. 5,

year of

State

19 U

19 US

New York

902

692

North Carolina

470

37

Kentucky

377

157

Pennsylvania

284

143

Virginia

205

61

The serious or threatening outbreaks this sum-
mer are confined almost entirely to states east of
the Mississippi, while last year’s were largely
west of the river.

o

THE DOCTOR FIGHTS
The dramatic development of surgery has re-
duced the death rate of war wounded in army and
navy hospitals to 3 per cent against 8 per cent
in World War I, Dr. Irvin Abell, chairman of
the board of regents of the American College of
Surgeons, told a nation-wide radio audience Tues-
day night. Speaking as the guest of Schenley
Laboratories, Inc., on the “The Doctor Fights”
program dedicated to the medical profession, the
distinguished Louisville surgeon cited the vast ad-
vancements in surgical technics during the pres-
ent century which have resulted in far greater
chances for the wounded to be restored to sound
health.

o

HEALTH OF NEW ORLEANS
The Bureau of the Census, Department of Com-
merce, reported that there occurred in New Orleans
the week ending July 15, 143 deaths, a very slight
increase over the previous week. Of these deaths
89 occurred in the white population, 54 in the
colored and 12 were in infants under one year of
age. The following week, closing July 22, showed
a rather small increase over the previous week;
of the 155 deaths listed that week 91 were white,
64 colored and 16 were in infants. There was a
sharp decrease in number of deaths occurring the
week which ended July 29; 22 less deaths in the
city than the previous week. Of the 133 deaths,
82 were white, 51 colored and 12 were children.
For the last week of which reports are available,
August 5, again there was a reduction in the num-
ber of people dying in this city. One hundred and
twenty-nine citizens of New Orleans expired, 85
of whom were white, 44 non-white and 14 were in-
fants under one year of age.

Louisiana State Medical Society News

147

INFECTIOUS DISEASES IN LOUISIANA
For the week ending July 8 the following dis-
eases were reported by the Louisiana State Depart-
ment of Health in numbers greater than ten: Ma-
laria 120 cases, bacillary dysentery 38, hookworm
23, mumps 22, measles 19, pulmonary tuberculosis
18, unclassified pneumonia 14, and septic sore
throat 13. In addition to these more commonly
reported cases there also occurred six cases of
typhus fever. There were nine cases of polio-
myelitis reported this week; five of which were
from Orleans Parish. Most of the patients reported
as having malaria were from East Carroll Parish
(70) and Jackson Parish (28). The following
week, which ended July 15, malaria still led other
reported diseases with 73 cases, followed by 30 of
pulmonary tuberculosis, 25 of mumps, 16 of ty-
phoid fever, 14 of unclassified pneumonia and 11
of poliomyelitis. The cases of this latter disease
were scattered over the state with Orleans Parish
reporting four and East Baton Rouge two. The
largest number of malaria cases came from East
Carroll Parish, with 35. There was a considerable
increase in number of cases of typhoid fever. Most
of these patients were repoi’ted from parishes in
the northern part of the state. For the week which
concluded July 22 there were listed 82 cases of
malaria, 38 of pulmonary tuberculosis, 26 of bacil-
lary dysentery, 24 of hookworm disease, 19 of
mumps, 15 each of typhoid fever, septic sore throat
and unclassified pneumonia. There were five cases
of poliomyelitis listed this week. The typhoid fever
patients for the most part came from Caddo Par-
ish. The following week, which terminated July
29, malaria had fallen to 29 cases but there were
22 cases of typhus fever listed and 14 of diphtheria
as well as 16 cases of unclassified pneumonia. Ty-
phus fever is almost as frequent this year as ty-
phoid fever; of the cases reported this week, came
four each from Acadia, Jefferson Davis, and Wash-
ington Parishes, three from Orleans and two from
Rapides. Report for the week ending August 5,
the week in which the mortality report of venereal
diseases is presented, showed for this particular
pei'iod 1335 cases of gonorrhea, 1136 of syphilis,
44 of chancroid and eight of lymphopathia vene-
reum. Other common diseases included 264 cases
of malaria, 125 of unclassified pneumonia, 46 of
pulmonary tuberculosis, 21 of poliomyelitis, 18 of
pneumococcic pneumonia and 10 of mumps. The
poliomyelitis cases included 11 which should have
been reported previously. No parish in the state
had more than two cases except Orleans Parish,
with seven cases. 'The total was reported by 13
parishes. From military sources came most of the
cases of gonorrhea which were reported but only

193 cases of the over one thousand cases of syphilis
came from this source. The malaria patients came
189 from Webster Parish and 45 from East Carroll.

DR. MARC MONROE MOUTON
1890-1944

The medical profession of Louisiana has suffered
the loss of one of its most distinguished members
when Dr. Mouton died the latter part of August
at his home in Lafayette.

Dr. Mouton was born in 1890 and graduated
from Tulane Medical School in 1913. He early
settled in Lafayette where for the last few years
he has been engaged in practicing his specialty of
eye, ear, nose and throat. When the reform gov-
ernment was elected in 1939, Dr. Mouton was se-
lected as Lt. Governor of the state. In spite of
the acrimonies that arise at the time, never was
a harsh word spoken about this doctor. He was
quiet and gentlemanly at all times and in every
respect. He was a man of strong personality yet
he accomplished his aims without leaving hard
feelings. As a doctor he was a real friend of man
and was beloved by his very large clientele. The
medical profession of Louisiana will mourn the
passing of this splendid character, who always had
the best interests of the medical profession near to
his heart.

o

DR. CHARLES E. HOMAN, JR.

1898-1944

Dr. Charles E. Homan, Jr., medical director of
the Ochsner Clinic, died suddenly of heart disease
while in his office the evening of July 25. Dr.
Homan became medical director of the Ochsner
Clinic in January, 1942. He was an extremely
well liked physician. Everyone who came in con-
tact with him admired him and appreciated his
always affable and pleasant manner. Like so
many physicians who know that they have organic
disease, he went ahead cheerfully in his chosen
field and worried not about the future, which he
well knew, at the best, could be only but brief.

Dr. Homan was a member of the Orleans Parish
Medical Society, the Louisiana State Medical So-
ciety and the American Medical Association, as
well as a member of the Amercan College of Phy-
scans.

o

DR. DANTAN WYETH LANDESS
1896-1944

Dr. D. W. Landess, a graduate of the University
of Tennessee in 1930 and since 1933 a member of
the State Society, died suddenly of a heart attack
on August 22 at the Lady of the Lake Sanitarium.
He was parish health officer of West Baton Rouge,
also a governor of Lions International and a high
ranking officer in the Louisiana State Guard.

148

Book Reviews

BOOK REVIEWS

Mcdcal Diagnosis: Applied Physical Diagnosis;
Edited by Roscoe L. Pullen, A. B., M. D. Phila-
delphia, W. B. Saunders Company, 1944. Pp.
1106. 584 illus. Price, $10.00.

The reviewer approached this large volume with
trepidation but quickly found that Dr. Pullen has
produced a unique book of considerable merit.
Thirty profusely illustrated chapters by twenty-
seven authors afford authoritative descriptions of
basic disorders in sufficient detail to make this an
extremely useful reference work for medical stu-
dents and general practitioners.

The individual contributions are inevitably not
of uniform quality but no other single-volume work
in English covers the specialties so thoroughly.
This reviewer is incapable of commenting intelli-
gently upon those chapters devoted to the exami-
nation of the skin, eyes, oral cavity, nose and
throat, breasts and female pelvis; they seem ade-
quate and the photographs are indeed good. Sode-
man’s section on the heart is outstanding in every
respect and the chapter on the neurologic exami-
nation is ingeniously illustrated. Of particular
utility is the section on anorectal disease and the
chapters describing the study of the urologic tract,
the skeletal system and the extremities provide
specialty education of textbook character. Dr.
Ochsner’s chapter, for example, includes a descrip-
tion of the technic of phlebography and of procaine
anesthetization of the sympathetic nervous system.
There are chapters on electrocardiography and
electro-encephalography, pediatric diagnosis, occu-
pational diseases and certain general aspects of
neuropsychiatry.

It is difficult to see why space was devoted to
such matters as military and insurance medicine.
It could have been more fruitfully occupied by a
critical description of endocrine disorders. Metab-
olic bone disease and disorders of the neuro-mus-
cular apparatus are neglected. There is also no
chapter on blood dyscrasias although leukemia is
briefly considered by the author of the section on
“Examination of the Neck.”

On the whole, Dr. Pullen has done an extraor-
dinary job in assembling this book under what must
have been difficult circumstances. Unfortunately,
the price is too great for the average medical stu-
dent.

Thomas Findley, M. D.

Safe Deliverance : By F. C. Irving, M. D. Boston,
Houghton, Mifflin Co., 1942. Pp. 308. Price,
$3.00.

This book is a combination of three interwoven
themes; the development of obstetrics in the past
hundred years, the history of the Boston Lying-In
Hospital, and the highlights of the author’s life.
They are very skillfully treated, and the result is
a most delightful volume, bubbling over with the

author’s humor, and filled with interesting stories
of the institution and of the personalities asso-
ciated with it during its hundred and ten years of
existence.

The history of this hospital gives us an insight
into the evolution of these institutions throughout
the country in the past century. The incidental
pictures of medical schools and of medical practice
during this period are most informative. Unless
one delves into such records, one cannot visualize
the remarkable advances in medical service, due
to developments in bacteriology, anesthesia, asep-
sis, etc., that have been made during this time.
As in other fields of human endeavor, there has
been more progress in the field of medicine in the
past century than in all previous time covered by
recorded history.

The author, being right on the scene, so to speak,
gives an interesting description of the first use of
anesthesia at the Massachusetts General Hospital,
and of the rather disgraceful squabble between
Morton and Jackson that followed. He gives proper
credit to Long, of Georgia, who was l-eally the first
person to induce anesthesia with ether, but who
did not establish his claim to priority by prompt
publication. The development of anesthesia and
analgesia in obstetrics since these early days is
then described.

The author writes of the scourge of puerperal
infection and its virtual elimination after the epoch
making work of Pasteur and Lister. The contro-
versy between Holmes and Meigs is described with
some rather left-handed compliments for the latter
gentleman. He discusses the history of cesarean
section and gives some rather interesting commen-
tary on its present-day frequency. He also touches
on the evolution of the management of eclampsia,
and stresses the value of the present-day policy
of conservatism.

He gives quite an interesting history of the ob-
stetrical forceps, which of course includes the story
of the Chamberlen family. To quote “After a so-
journ in Scotland, he (Hugh Chamberlen, Sr.) set-
tled in 1693 in Amsterdam, where he made the ac-
quaintance of Roger Roonshuysen, an obstetrician
of that city.” Let us assume that Roger was at
least 25 years old by this time. Hugh is said to
have sold the secret of the forceps to Roger, who,
in 1747 (54 years later), managed to have a munici-
pal law passed obliging other physicians to pur-
chase the secret from him or from his associates.
However, in 1732 (note the date) Rathlaw, an-
other obstetrician of the city, refused to buy the
secret, and persuaded Velsen, of The Hague, to
help uncover the mystery. Velsen, in turn, handed
the job to Van der Schwann, a student of Roon-
shuysen, aged, say 20. The master was foxy, and
the student was persistent. He dogged Roger’s
steps for 61 years (so says the book), and finally

Book Reviews

14»

(well said, Dr. Irving), finally, in 1793, the “keen-
eyed pupil” (now aged 81; some eyes) managed
to secure the instrument and to make a sketch of
it. One can only admire the ruggedness of the
master and the determination of the pupil. Roger
was still going strong in the practice of obstetrics
at the age of 125; Van der Schwann, forsaking all
ambition to establish a private practise (and prob-
ably forswearing matrimony as well), remained a
pupil for 61 years, sleuthing all the while. Some
men; some typesetter; some proofreader.

But to continue. The book can be heartily com-
mended for its subject matter, its style, its humor,
and the manner of presentation. It is most in-
formative, and at the same time most delightfully
written. It can be enjoyed by non-medical indi-
viduals as well as by doctors; it reads like a novel
and is much more worth while.

E. L. King, M. D.

Laboratory Methods of the United States Army.

Edited by James S. Simmons, B. S., M. D., Ph. D.,

D. P. H. Sc. H. (Hon.) and Cleon J. Gentzkow,

M. D., Ph. D., Philadelphia. Lea and Febiger,

1944. Pp. 823. Price $7.50.

This book, intended as “a manual describing
practical methods for use in the medical and sani-
tary laboratories of the Army,” has been com-
piled by the editors from the collaborative efforts
of twenty-five contributors, many of whom are
outstanding authoi'ities in their respective fields.
The result is an excellent compendium, with a
wealth of useful information presented in compact
yet readily accessible form. The tables summariz-
ing data are exceedingly helpful. There are nu-
merous maps indicating the geographic distribu-
tion of various diseases and there is an abundance
of excellent illustrations, many of them colored
plates.

The contents of the book include sections on
clinical pathology and chemistry, mycology, bac-
teriology, rickettsiae and filtrable viruses; proto-
zoology; helminthology; entomology; pathology;
special veterinary laboratory methods; statistical
methods. Aside frorp the material usually pre-
sented in such a book as this, there are numerous
very useful additions, e.g. discussions of methods
for liver and kidney function tests, hormonal tests
ior pregnancy, determination of the levels of vita-
mins, atabrine, quinine and penicillin in body fluids.
This reviewer is particularly favorably impressed
by the conciseness of the comprehensive presenta-
tions of hematology and chemistry of the blood; the
rickettsiae and filtrable viruses; protozoology; and
entomology.

There is often a tendency for a reviewer to be
hypercritical of the work of others in the field of
one’s personal interest and this temptation should
be resisted strongly. Nevertheless one cannot help
feeling that there are several places in the discus-
sion of bacteria of medical importance where the

presentation does not seem to reflect the full ap-
preciation of recent advances. For example, the
typing of Group A streptococci by Lancefield’s
precipitin method is not mentioned and the prepara-
tion of extracts for grouping is not described; the
serologic typing of meningococci by means of cap-
sular swelling is deprecated; the importance of
Hemophilus influenzae type B in meningitis and
rapid diagnosis of this infection with the aid of
Quellung are not considered; the practical useful-
ness of skin tests with bacillary antigens (as com-
pared with cultivation of the etiologic organisms)
in cases of chancroid is not discussed. It is wholely
unnecessary to subculture to Endo’s or eosin
methylene blue agar positive cultures obtained
from a patient’s blood, as suggested (p. 479). It
also seems a work of supererrogation to inoculate
pure cultures isolated from fecal plates to both
Russell’s and plain agar slants, then to utilize the
latter for cultural or serological identification if
the reactions in Russell’s double sugar medium in-
dicate the group to which the organism belongs (p.
480). It is difficult to see why space is devoted
to the genera Noguchia and Dialister in a book de-
voted to practical laboratory methods, since these
organisms are not today regarded as of etiological
significance and are unlikely to be sought for by
anyone using the manual. The foregoing com-
ments are not however to be taken as indicating
that the reviewer is unfavorably impressed with the
treatment of pathogenic bacteria as a whole.

There is no question but that this book will have
a wide circulation and influence which it eminently
merits. It will be in constant use by those inter-
ested in clinical pathology, human and veterinary
infectious disease, sanitary science and others, who
are fortunate enough to have a copy at hand. Its
purchase is highly recommended.

Morris F. Shaffer, D. Phil.

The Electrocardiogram, Its Interpretations and

Clinical Applications : By Louis H. Sigler, M. D.,

F. A. C. P. New York, Grune & Stratton, 1943.

Pp. 1074. Price, $7.50.

This volume of three hundred and ninety-one
pages is divided into twenty-five chapters. In the
first chapter the electrocardiogram is discussed
with regard to the electrophysical, anatomical and
electrophysiologic basis. There are seven diagrams
in this chapter that are simple and comprehensive
and should give the beginner a good knowledge of
the fundamentals.

In the next chapter the recording of the heart
current is described and the methods of applying
the electrodes in the limb leads and the location of
the precordial electrodes for the chest leads. In
this chapter he makes the statement, “Although the
so called fourth lead is now almost universally used,
and often gives us information when the standard
leads fail to do so, it does not give us all the in-
formation we desire.” He thinks it is essential

150

Book Reviews

that we obtain more than one precordial lead. With
this the reviewer agrees for he is of the opinion
that from middle life onward or in any one when
coronary disease is suspected, not only all of the
six precordial leads be made but one made from a
point to the left of the ensiforme. This may show
best the presence of a posterior inferior infarct.
If the heart is greatly enlarged it may be necessary
to go as far as the posterior axiliary line on a level
with the apex beat.

In the chapter on The Normal Electrocardiogram
it is stated, “It is true that marked abnormalities
of the electrocardiogram probably rarely occur
with a perfectly normal heart. Yet as our experi-
ence in electrocardiography advances, more and
more electrocardiographic features previously con-
sidered as due to heart disease are found to occur
in individuals who show no clinical evidence of such
disease.” This is in keeping with the reviewer’s
experience and opinion. There are reproductions
of ten varieties of electrocardiograms obtained from
normal adults. These reproductions are well done.
They are clear cut and easy to read in detail. They
include three limb leads and IV F.

In the chapter on The Electrical Axis he gives a
description of the different methods used. One
would gather that he thinks that the determination
of the electrical axis of the QRS complex from the
mere appearance of the electrocardiogram is ac-
curate enough for ordinary use.

Under the abnormal electrocardiogram classifi-
cation he emphasizes the importance of repeating
the electrocardiogram at intervals and that signifi-
cant changes in the curves indicate structural or
functional abnormalities in the heart even if each
individual tracing is of normal appearance. This is
true and important and is constantly being over-
looked. He divides the abnormal electrocardio-
gram into two parts. First the disturbance of
the cardiac mechanism — second, abnormalities in
the electrocardiographic patterns. He devotes one
hundred thirty-five pages to the discussion of dis-
turbances in the cardiac mechanism. This includes
abnormalities due to disturbances in the sinus node;
interruption of the sinus rhythm by ectopic im-
pulses; displacement of the pacemaker; the pa-
roxysmal tachycardias; flutter and fibrillation;
the varieties of block; etc. There are many repro-
ductions that are good with each one. There are
a few words about the age, sex of the individual
and clinical diagnosis with a discussion of the ab-
normalities seen in the electrocardiogram.

Under other abnormalities in the electrocardio-
gram he discusses the abnormalities of the P wave,
the QRS complex, ST segment, T wave, QT interval
with reproductions of curves showing these ab-
normalities with clinical diagnosis and with a de-
scription of the abnormalities. He stresses the im-
portance of correlating the electrocardiogram with
the clinical findings. He devotes thirteen pages to
the anatomic and physiological features of the cor-

onary circulation and its abnormalities. This chap-
ter reflects fairly well the accepted opinions on this
subject.

Coronary disease is discussed under Acute Coro-
nary Insufficiency and Chronic Coronary Insuffi-
ciency. Under the first he includes in his discus-
sion acute myocardial infarct; acute transit myo-
cardial ischemia with electrocardiograms showing
different types. Under chronic coronary insuffi-
ciency he places angina pectoris and mentions the
varieties of the electrocardiographic changes seen
in coronary sclerosis.

The subject of ventricular preponderance and of
electrical axis deviation of the QRS complex is
treated in two separate chapters.

Under ventricular preponderance he discusses the
curves seen in right and left ventricular hyper-
trophy. These include the three limb leads and
IV F. The chest leads from over the right and
left side of the precordia might have been of addi-
tional aid.

The chapters on Myocarditis, Trauma of the
Heart, Electrocardiographic Changes in Various
Constitutional and Toxic States, The Effect of
Drugs, and bring out the accepted views on these
subjects.

The last chapter of twenty-one pages is devoted
to the description of the precordial leads — CW 1
through CF 6 — both normal and abnormal with a
comparison of the CR & CF leads.

The bibliography at the end of each chapter falls
short in some but is sufficient in most. The book
is well printed and easy to read. It is stated in the
preface that the book is an attempt to put the elec-
trocardiagram in its proper perspective. One could
hardly say that this has been fully accomplished.
As a whole the reviewer feels that he can recom-
mend this book to those interested in this subject.

J. M. Bamber, M. D.

PUBLICATIONS RECEIVED

D. Appleton-Century Company, New York:
Fundamentals of Internal Medicine, by Wallace M.
Yater, M. D., F. A. C. P.

Lea and Febiger, Philadelphia: Surgical Disor-
ders of the Chest, by J. K. Donaldson, M. D.,
F. A. C. S.

J. B. Lippincott Company, Philadelphia: The Art
of Anesthesia (7th Edition), by Paluel J. Flagg,
M. D.

The University of Chicago Press, Chicago: X-ray
Examination of the Stomach, by Frederic E.
Templeton, M. D.

The Williams & Wilkins Company, Baltimore:
Clinical Urology (Second Edition), Vol. I and Vol.
II, by Oswald Swinney Lowsley, A. B., M. D.,
F. A. C. S. and Thomas Joseph Kirwin, M. A.,
M. S., M. D., F. A. C. S. Manual of Urology
(Third Edition), by R. M. Lecomte, M. D.,
F. A. C. S.

New Orleans Medical

and

Surgical Journal

Vol. 97 OCTOBER, 1944 No. 4

THE DOCTOR AND SOCIALIZED
MEDICINE*

WALDEMAR R. METZ, M. D.

New Orleans

For the first time in the 66 years of the
existence of this Society a president has
called a special meeting to be known and
designated — “Past Presidents’ Night.” The
purpose of this unprecedented session is to
do honor to those, who in preceding years,
have wielded the gavel over this organiza-
tion. It is to be a recognition of their faith-
ful and conscientious service to organized
medicine. It is a testimonial and an appre-
ciation of their labors and their accomplish-
ments, a tribute to the time they have so
freely given, the efforts they have expended
and the thought they have devoted to the
interests and the welfare of this body. It
could be, of course, accepted also as perhaps
a little taffy that is being fed to us to
sweeten the inroads of the passing years,
to help us feel that our usefulness to the
cause is not entirely spent and that the
hardening of our cerebral vessels has not
progressed to too alarming or too critical
a degree.

I feel particularly honored in being asked
to take part in the exercises on this occa-
sion, because there are so many of my fel-
lows in this long line of Past Presidents
whose talents and abilities far out-weigh
my own and who could more adequately and
more competently do justice to this pleasur-
able assignment. Suffice to say that I am
delighted to be the means of expressing, on

*Read before the special meeting of the Orleans
Parish Medical Society honoring past-presidents,
May 22, 1944.

this significant evening, the gratitude and
the thanks of the Past Presidents for this
generous gesture on the part of the Society
and its Officers.

There are those in past years who have
presided over this Society with dignity and
ableness, and who have brought to the of-
fice great executive ability. Their judg-
ment and their courage have, with the aid
of their respective Boards, weathered heavy
storms in the past inimical to the inter-
ests and the future of the profession, and
on an even keel have again guided the
affairs of the Society into tranquil and
peaceful waters. To these men we owe a
genuine debt of gratitude. They have car-
ried out the duties of their office to the full
for they were men of character and prin-
ciple. This Society has been quite fortu-
nate in having as its head a number of such
Presidents in the past.

It is customary to felicitate a man on his
accession to a high office, and rightly so,
for he is to be congratulated on his advance-
ment and he needs the good will, the best
wishes and the cooperation of his associates.
Unfortunately, glory and honor always
carry with them responsibilities and obliga-
tions and it is not at all an uncommon
observation to find those in high places who
forget these handicaps of adulation. They
become self-centered, self-sufficient and
sublimely oblivious to what is justly ex-
pected of them. To be sure these are
always men of personality and character,
but they lack the co-partner of character
which is principle. As someone has quite
correctly said, “Character by itself cannot
be trusted without principle.” There are
many examples which show this to be true

152

Metz — Socialized Medicine

— history is replete with men of strong
character uncontrolled by principles who
have proved themselves unsafe to follow.
Caesar and Napoleon and now Hitler are
examples of great talent and executive abil-
ity under the control of inordinate ambition
instead of moral principle. There are many
others who, mighty in intellectual power
and energy, enabling them to reach dizzy
heights, have done great harm because their
practice was abominable for want of prin-
ciple.

In its long and honorable history, in its
brilliant and praiseworthy traditions, the
medical profession never more sorely
needed men of character and principle
than it does today. We are faced with
powerful enemies from without, who would
destroy the ideals and practices of Aescu-
lapius and Hipprocrates, who would tear
down the great principles to which genera-
tions of physicians have dedicated their
lives.

Medicine is the oldest of the professions ;
it antedates the Christian religion ; it is
older than the civil law. It embraces all
qualified professional competitors, but this
must be a healthy and not a baneful com-
petition. One of the objectives of organized
medicine is to establish fair and equitable
means through which healthy competition
may be maintained without detriment to
the profession as a whole. Organized medi-
cine strives to improve and to build by set-
ting up an ideal for each individual prac-
titioner, knowing that as the individual is
benefited, the profession as a whole will
advance. In thinking of the accomplish-
ments of the builders in other vocations we
find that the outstanding ones are those
who build upon foundations of service —
those of us who live and work in organized
medicine will be those who have served.

Today, organized medicine is beset upon
many fronts by evils which seek to disrupt
all that is good and worth while in the prac-
tice of medicine. As we observe the radical
forces which seek to force a place for them-
selves in our social make-up, it seems
amazing and incredible that such influences
should find nourishment in our American

soil of free enterprise and individual indus-
try. It is a unique and characteristic result
of even minor social revolutions that they
become progressively aggressive and in-
creasingly demanding — and we of the medi-
cal profession had best look to our knitting
and defend the character and principles of
medical practice with all the power at our
disposal. Our defence should start as indi-
viduals, with more loyalty to our Parish
and State Medical Societies and more loy-
alty of the Parish and State Medical Socie-
ties in their turn to the parent organization
— The American Medical Association — for
the need of a united stand has never been
greater.

Some doctors are represented to be un-
troubled by these invasions into the field
of medicine for they are independently
wealthy and are devoid of the aims and the
ideals of the healing art — they are doctors
by Medical School decree, but that only —
they possess neither the character nor the
principle, the sympathy or the understand-
ing of the true physician and his relation-
ship with the sick, the needy and the
maimed — some there are who are reported
to have linked their abilities with political
possibilities and will be on the ground
floor, no matter what may happen — others
are possessed of that innate quality which
renders them deaf, dumb and blind to all
except the immediate problems of teaching
and research. If political medicine be-
comes a reality these gentlemen will find
no incentive either for teaching or for re-
search— but to offset these, we have in our
ranks the priests of medicine, the bearers
of the standard, those upon whom the
Caduceus is indelibly stamped, the self-
sacrificing, the faithful and the loyal ; such
a diversity of temperament and opinion is
possible only because of the democratic na-
ture of medical organization. In the pres-
ent emergency, however, petty differences
and small jealousies must be laid aside in
the interest of united action, not only for
the preservation of the present system, but,
indeed, for the welfare of the entire nation.

The present system of dispensing medi-
cal care insures the health of our citizens —

Palik and Moss — Rabies

153

such changes as may be necessary must
come from the profession itself, whose
democratic principles permit of free dis-
cussion and majority action — it is the re-
sponsibility of each individual physician to
study, and to work, in so far as his busy
days permit, toward the preservation of the
sound American traditions of medical
practice.

Search for truth, self-sacrifice and al-
truism have ever been present in doctors
of medicine and as long as these prevail
the health of the country will remain at
the highest level which it is possible to
maintain. We owe it to our medical com-
rades in the Armed Forces here and in for-
eign lands, to fight for their interests, so
that when they come back to us we may
truthfully say that we have kept the faith,
that we have protected our common ideals
and medical traditions. The practice of
medicine may not be just as they left it, to
be sure, but at least they will recognize it
and can take up where they left off and
earn their reward by individual effort —
not by political preference.

Past Presidents of the Orleans Parish
Medical Society to whom this meeting is
dedicated — the silver lining to this per-
nicious cloud of regimented medicine lies
in the fact that in every parish, county,
city, state and national medical body there
are older leaders — Past Presidents many —
whose maturer years and experience equip
them best to fight for the unfettered and
the free pursuit of our vocation.

This Society salutes you Past Presidents ;
you well deserve their recognition and may
your years of continued service be many.
Our President, Dr. Zander, is setting a pre-
cedent for constructive activity in advanc-
ing the interests of this Society. His ad-
ministration will go down, I feel sure, as
one of the most productive in the annals
of this organization. He seeks your ad-
vice, he seeks your counsel and your active
participation in the business affairs of the
Society and none of you, I know, will deny
it to him.

The appeal for man power is nation wide
— in every avenue of endeavor there is a

great clamor for men — but in no profes-
sion is there greater demand for man power
than is ours at this time — the power and
the influence of men of character and of
principle.

In closing may I quote to you these words
of J. G. Holland who said:

Men whom the lust of office does
not kill,

Men whom the spoils of office can-
not buy,

Give us men

Men from every rank,

Fresh and free and frank;

Men of thought and reading,

Men of light and leading,

Men of faith and not of faction,

Men of lofty aim and action;

Give us men — I say again!

Give us men!

o

RABIES*

A TEN- YEAR SURVEY OF THE PASTEUR

INSTITUTE OF CHARITY HOSPITAL
OF LOUISIANA AT NEW ORLEANS

EMIL E. PALIK, M. D.f
and

EMMA S. MOSS, M. D.f
New Orleans

DEFINITION

Rabies is an acute infectious and con-
tagious disease affecting many species of
animals. It is caused by a neurotropic
filtrable virus. The infectious agent is
transmitted from animal to animal by the
introduction of infected saliva through the
broken skin usually by the bite of a rabid
animal. The disease is invariably fatal to
man and is generally fatal to other species
of infected animal.

HISTORICAL

Rabies has been known since ancient
times. Aristotle1 recognized the disease and
the fact that its mode of transmission was
by the bite of a rabid dog. Galen1 recom-
mended the excision of wounds inflicted by

*Read before the Orleans Parish Medical So-
ciety, November 6, 1943.

fFrom the Department of Pathology of Charity
Hospital of Louisiana at New Orleans and the
Department of Pathology and Bacteriology, Lou-
isiana State University School of Medicine.

154

Palik and Moss — Rabies

the bite of a rabid dog to prevent develop-
ment of the disease. The infectivity of the
saliva for dogs was demonstrated by Zinke2
in 1804 ; for herbivora, by Berendt2 in 1822 ;
and for man, by Magendie.2 By injecting
saliva from a rabid dog into the brains of
rabbits, Galtier2 studied the etiology of and
immunization against the disease in 1879-
1881. In 1881-1889 Pasteur proved that the
etiologic agent was chiefly concentrated in
the central nervous system. He prepared
an infectious material of known and con-
stant virulence from infected brains and
spinal cords and used it in immunization
against the disease. The filtrability of the
etiologic agent was demonstrated by Rem-
linger2 and Riffat Bey2 in 1903. The dis-
covery of specific inclusion bodies in the
central nervous system by Negri2 in 1903
facilitated the diagnosis of the disease. The
Health Organization of the League of Na-
tions,3 founded after the first World War,
was responsible for gathering valuable data
concerning the disease and the results of
its treatment.

GEOGRAPHIC DISTRIBUTION

Rabies is a cosmopolitan disease which
has occurred in all parts of the world ex-
cept in Australia and Hawaii.4

For several years in the beginning of the
nineteenth century in Europe the disease
prevailed as an epizootic. Wolves, foxes
and domestic animals were affected par-
ticularly but the disease was also observed
in man. The incidence increased over the
whole European continent and British Isles
between 1819 and 1829. Subsequently,
many countries were entirely free from the
disease. It became prevalent again particu-
larly in Central Europe, following the first
World War. Since then attempts have been
made to eradicate the disease by rigid en-
forcement of control measures, and Great
Britain, Denmark, Sweden, Norway, Bel-
gium and Switzerland have been free from
rabies for many years.

In North America, rabies was formerly
widespread and is still endemic in many
localities in the United States. Denison and
Dowling5 state that “Birmingham has been
considered by some as the ‘rabies capital of

North America and possibly of the civilized
world.’ ” During the seventeen years from
1922-39 in Alabama, 11,218 animals were
diagnosed positive for rabies by laboratory
examination, 42,947 individuals received
anti-rabies vaccine and 48 persons died of
the disease.

EPIDEMIOLO'GY

Rabies is primarily a disease of carnivo-
rous animals. From 80 per cent to 90 per
cent of the cases occur in dogs. Cats, wolves,
foxes and other carnivorous animals may
also develop and transmit the disease. In
Trinidad and South America the vampire
bat is subject to infection and causes spread
of the disease. Man is secondarily infected
by exposure to rabid animals.

INCUBATION PERIOD

The incubation period of rabies following
exposure varies within wide limits. Cases
can occur within ten days but may be de-
layed as long as two years following the bite
of a rabid animal.1 The average period
seems to be about two months.

PATHOGENESIS

The virus is conveyed mainly by way of
the nerves from the lacerated area of a
bite to the central nervous system. The
lymph and blood stream may also dissemi-
nate the virus throughout the body.

PATHOLOGY

The significant lesions are present in the
central nervous system. The presence of
hyperemia and edema are the only gross
anatomic changes. Microscopically, the
lesions which are both degenerative and in-
flammatory occur chiefly in the segment
of spinal cord or brain which receives the
nerves from the site of inoculation of the
virus. The degenerative changes consist
of vacuolization, hyalinization and chroma-
tolysis of the nerve cells. Inflammatory
changes are characterized by foci of edema,
hyperemia, petechiae and diffuse and peri-
vascular polymorphonuclear leukocytic in-
filtration. Later, the lesions consist of
areas of gliosis infiltrated by macrophages
and lymphocytes. These changes, while
characteristic, are not pathognomonic of
rabies, since they occur in other types of
encephalomyelitis.

Palik and Moss — Rabies

155

The pathognomonic feature of the dis-
ease is the presence of Negri bodies within
nerve cells of the central nervous system.
Typically, these bodies are ovoid or rounded
and vary from one to thirty microns in size.
Their size may vary markedly in a single
brain. The majority may be large, medium
sized or so small as to be visible only when
viewed under the oil immersion objective
of the microscope. They stain red with
eosin-methylene blue, may be homogene-
ously glassy or granular and contain one
or more round or rod-like granules. These
granules may be located centrally, peri-
pherally, or may be diffusely scattered.
They measure from 1 to 4 micra in size and
stain dark or light blue. In rabbits affected
with fixed virus, Negri bodies may be ab-
sent or appear as tiny eosinophilic granules.

The exact nature of the Negri bodies is
unknown. Negri regarded them as para-
sites and as the etiologic agent of rabies.
Others regard them as degenerative prod-
ucts of cells. The majority of observers
however, regard them as the etiologic agent,
representing virus-colonies. They are pres-
ent most abundantly in the hippocampus
and cerebellum but may also be numerous
in the medulla, basal ganglia and cerebral
cortex. As a rule, their size and number
are directly proportional to the duration of
the symptoms. Exceptions to this are so
frequent, however, that reliance cannot be
placed on this generalization.

RELATION OF SYMPTOMS TO LESIONS

The symptoms are dependent upon the
progression of the pathology. In the early
stage of the disease the action of the virus
is one of stimulation of the cells of the cen-
tral nervous system. The first symptom is
frequently pain at the site of the bite, be-
cause of changes in the spinal cord cor-
responding to the segment receiving the
nerves from the site of inoculation. As the
brain becomes affected, the classical symp-
toms of increased nervous excitability, rest-
lessness, apprehension and bizarre behavior
become manifest. At this stage of the dis-
ease carnivorous animals, such as the dog,
are apt to be vicious, and humans are bi-
zarre in their behavior. As the disease

progresses, the effects of irritation and
stimulation are replaced by paralyses which
result from degenerative changes in the
nerve cells. The voluntary muscles become
paralyzed at the level corresponding to that
of the spinal cord involvement. The paraly-
sis ascends and when the medulla becomes
involved the vital centers are destroyed.
One of the most common terminal manifes-
tations of the disease is paralysis of the
muscles of respiration. The hyperglycemia,
glycosuria, polyuria and hyperpyrexia so
commonly present are probably due to path-
ologic changes of the brain stem in the
vicinity of the fourth ventricle.

DIAGNOSIS OF RABIES

Although a presumptive diagnosis of
rabies in animal and man can be made from
the symptoms by an experienced observer,
a positive diagnosis in either can be made
only after death. In this respect rabies
differs from other infectious diseases in
which laboratory tests confirm the diag-
nosis on the living patient.

The symptoms which lead to a presump-
tive diagnosis in animals include change of
disposition and character, wandering, rest-
lessness, avoidance of familiar environment
and persons, uneasiness, tendency to bite,
change of appetite, tremors, salivation,
paralyses, especially of the extremities or
lower jaw, and convulsions. Many of the
same symptoms occur in man. The history
of a bite by a suspicious or proved rabid
animal provides additional evidence.

A positive diagnosis may be established
by microscopic or biologic examination of
the brain tissue of an animal that has died
or has been killed following prostration
from fully developed rabies.

The microscopic demonstration of typical
Negri bodies in the brain tissue of a sus-
pected animal establishes the diagnosis.
Two technics are in use for the demonstra-
tion of Negri bodies. One is the impression
method in which unfixed sections of Am-
mon’s horn are impressed on slides and dif-
ferentially stained. This method is rapid
but less accurate than the second technic,
the fixed paraffin section method. In this

156

Palik and Moss — Rabies

method, sections of cerebellum and Am-
mon’s horn are fixed and dehydrated in
acetone, embedded in paraffin, sectioned
and stained with differential stains.

The final, conclusive test for rabies is
animal inoculation. Formerly rabbits were
used for the test but these were unsatisfac-
tory because the incubation period varied
from animal to animal and was frequently
from two to six weeks. Recently, white
Swiss mice, two to three weeks old, have
been found to be highly susceptible to the
virus of rabies. The suspected material is
injected intracerebrally. If the virus is
present, the mouse will become ill on the
seventh to tenth day, and die on the ninth
to twelfth day. The brain will show Negri
bodies after the fifth or sixth day. Inocu-
lation tests, though conclusive, are time con-
suming and require facilities and personnel
which are not always available. Accuracy
has been stated to be 4 per cent to 10 per
cent greater than that obtained by direct
examination of the brain for Negri bodies.

NATURE AND PROPERTIES OF RABIES VIRUS

The discovery by Remlinger and Riffat
Bey2 in 1903 that the infectious agent of
rabies was a filtrable virus has been con-
firmed by numerous investigators.

Two types of virus are recognized: (1)

street virus is the type which is found oc-
curring naturally in animals; (2) fixed vi-
rus used in the preparation of anti-rabies
vaccine is that type in which certain proper-
ties have become fixed and constant. The
two types differ markedly in their charac-
teristics.

Street virus is characterized by: (1) a

long incubation period following inocula-
tion; (2) relatively high infectivity follow-
ing peripheral inoculation; (3) production
clinically of either the manic “furious” or
the paralytic “dumb” type of disease, and
(4) the presence of Negri bodies in the
nerve cells especially of Ammon’s horn and
the cerebellum.

Fixed virus is produced by serial passage
of street virus through animals, chiefly the
rabbit or mouse. The number of such
passages required to fix a virus varies from

strain to strain. The ordinary street virus
requires from 30 to 50 passages. Other
very virulent strains known as reinforced
strains become fixed after relatively few
passages. Strains of very low virulence are
resistant to fixation even after prolonged
passage. Fixed virus is characterized by:
(1) a short incubation period of five to
eight days; (2) a decrease in susceptibility
of animals to the virus when they are in-
jected by other than the intracerebral or
subdural route; (3) development of the
paralytic type of disease, and (4) the dis-
appearance or reduction in size of the Negri
bodies.

In 1936 Galloway and Elford,6 using the
collodion membrane ultra-filtration technic,
reported the size of fixed virus to be be-
tween 100 and 150 milli micra. Paic, et
al.,° in 1938 estimated the size of street
virus to be between 160 and 240 milli micra.

TREATMENT

Treatment is divided into two phases,
local treatment and prophylactic immuniza-
tion. Many authorities recommend local
treatment similar to that employed for any
other type of wound and in addition cauteri-
zation with fuming nitric acid as early as
possible following the injury. The prophy-
lactic immunization against rabies was in-
troduced in 1884 by Louis Pasteur and has
come to be known as the Pasteur treatment.
The vaccines employed throughout the
world today consist of emulsions of rabbit
brain or spinal cord, containing either liv-
ing or killed fixed rabies virus. The Semple
type of phenol-killed vaccine is most com-
monly employed. Some of the major ad-
vantages offered by the use of this type of
vaccine are: (1) decentralization of treat-

ment; (2) infrequency of neuroparalytic
accidents, and (3) simplicity of manufac-
ture.

SEMPLE VACCINE

Semple vaccine is prepared from the
spinal cords and brains of rabbits which
have been infected with fixed rabies virus.
The finished vaccine consists of a 4 per
cent emulsion of nervous tissue in physio-
logic saline containing phenol in 0.5 per
cent concentration.

Palik and Moss — Rabies

157

METHOD O'F ADMINISTRATION OF
ANTI-RABIC VACCINE

Our method of treatment is a daily, 2 c. c.
subcutaneous injection of the vaccine until
a total of 18-25 injections has been given.
Patients bitten on the extremities or trunk
receive 18 injections, whereas those bitten
on the head, face or neck or those who have
sustained multiple, severe lacerations re-
ceive 21-25 injections. Although the injec-
tions may be given in any part of the body,
the arms and abdomen are the usual sites of
election for vaccination. Because of minor
local aseptic inflammatory reaction which
not infrequently occurs, it is advisable not
to administer the vaccine in the same loca-
tion over two successive days.

INDICATIONS FOR PASTEUR TREATMENT

The Pasteur treatment is given to any
person who has been bitten or scratched by
a rabid dog or in whom the saliva of such
a dog has reached any recent, open wound.
Patients bitten or scratched by a stray dog,
in which the presence of rabies cannot be
excluded should also receive Pasteur treat-
ment. It is not advised in any other type
of exposure. However, in some instances
where definite bite or scratch by a rabid
animal cannot be ruled out, as is frequently
the case with infants or children, the Pas-
teur treatment must be given, especially
in a community where rabies is prevalent.

COMPLICATIONS FOLLOWING PASTEUR TREATMENT

Benign reactions, such as general mal-
aise, fever, headache, local erythema at
the site of injection and urticaria, are of
frequent occurrence during the administra-
tion of Pasteur treatment. They are of no
grave consequence and should not influence
the patient to discontinue treatment before
completion of the prescribed course. Sub-
cutaneous abscesses due to faulty aseptic
technic may also occur.

Severe reactions such as neuroparalytic
accidents are extremely rare. World wide
reviews3 place the incidence at about one
in 8,000 cases treated with phenolized vac-
cines and about one in 3,500 cases treated
with vaccine containing virulent rabies
virus. They may occur in the form of peri-
pheral neuritis, usually involving the facial

nerve, or as an ascending myelitis, the most
severe form of which, the Landry type, has
a mortality of about 30 per cent. They
occur during the latter part of the course
of treatment, being most frequent in the
apprehensive and intellectuals. They rarely
occur before 15 years of age. Recovery,
which may be rapid and complete, or slow
and incomplete, is the rule. The cause is
unknown.

PASTEUR INSTITUTE OF CHARITY HOSPITAL OF
LOUISIANA AT NEW ORLEANS

The Pasteur Institute of the Department
of Pathology of Charity Hospital was estab-
lished in October, 1903, by special resolu-
tion of the Board of Administrators of the
hospital.7 The Institute began to admin-
ister Pasteur treatments to patients on
December 20 of that year. During the first
year, 1904, anti-rabies vaccine was admin-
istered to 143 patients and of these two died
of rabies. The following year 118 were
treated, with one death.

From 1903 to 1910 the original live dried
cord vaccine of Pasteur was in use. From
1910 to 1929 the Harris method was em-
ployed in manufacturing the vaccine. This
is also considered to be a live vaccine and
is prepared by freezing with C02 snow and
dialysis in vacuo. In 1929 the Semple type
of phenol killed vaccine was adopted and
is the method in use at the present time.

The functions of the Pasteur Institute
are: (1) the diagnosis of rabies from the

brains of suspected animals and man; (2)
manufacture of anti-rabies vaccine, and
(3) administration of anti-rabies vaccine
to persons bitten or injured by known rabid
or stray animals.

The following survey comprises an analy-
sis of 12,237 patients admitted to the Pas-
teur Institute Clinic and 3,003 animal
brains submitted to the Pasteur Institute
for examination and diagnosis during the
period from January 1, 1934, to October
31, 1943, inclusive.

The data from these materials were ana-
lyzed according to the following points :

1. The number of patients who received
treatment.

158

Palik and Moss — Rabies

2. The number of animal brains found
positive for rabies.

3. The species of animals causing the
exposure and the deaths from rabies.

4. The incidence of rabies in each of the
10 years surveyed.

5. The influence on mortality of injury
by a proved rabid animal or by a stray
animal.

6. The influence of the location of the
injury on mortality.

7. The influence of the interposition of
clothing on mortality.

8. The influence of race on mortality.

9. The influence of the interval of time
between exposure and initiation of treat-
ment on mortality.

THE NUMBER OF PATIENTS WHO RECEIVED
TREATMENT

Twelve thousand two hundred and thirty-
seven patients applied to the Pasteur Clinic
(table 1). All of these patients applied be-

TABLE I

TOTAL NUMBER OF PATIENTS APPLYING TO

PASTEUR INSTITUTE CLINIC FOR TREATMENT
FOLLOWING EXPOSURE TO SUSPECTED
RABIES

Jan. 1, 1934 to Oct. 31, 1943 inclusive
Total patients

applying to Pasteur

Pasteur treatment

Clinic Treated unnecessary

12,237 4,146 8,091

cause of some type of exposure to a proved
rabid animal or to one suspected of having
rabies. It was deemed unnecessary to ad-
minister prophylactic treatment to 8,091 of
these; preventive treatment was admin-
istered to 4,146.

The type of exposure to rabies virus de-
termined whether or not the patient re-
ceived treatment. If the animal remained
alive and well, or if the dead animal was
proved not to have rabies, or if the exposure
was so indirect that in our opinion there
was no possibility of contracting rabies,
anti-rabies vaccine was not administered.

Of the 4,146 patients who received treat-
ment 3,273, or 79 per cent, were treated
because they had been injured by a rabid
animal. Only 873, or 21 per cent, received

treatment because of exposure without in-
jury. This latter figure is considerably
lower than that reported from Birmingham
by Denison and Dowling5 who state that
43.3 per cent of the persons on whom they
have data received treatment without hav-
ing been bitten. The problem in Birming-
ham concerns rabies in home-owned dogs
or pets while unidentified strays largely
constitute the problem in New Orleans. It
would seem therefore that there is greater
likelihood of injury being caused by the
stray dogs, while exposure without injury
is more likely in pet dogs.

THE NUMBER OF ANIMAL BRAINS FOUND POSITIVE
FOR RABIES

A total of 3,003 animal brains were sub-
mitted to the Pasteur Institute for exami-
nation and diagnosis (table 2). One thou-

TABLE 2

ANIMAL BRAINS EXAMINED, PASTEUR INSTITUTE

Per

cent

Positive for Negri bodies 1,303 43.4

Negative for Negri bodies 1,573 52.4

Unsatisfactory for examination 127 4.2

Total 3,003 100.0

sand three hundred three, or 43.4 per cent,
of these were positive for Negri bodies by
microscopic examination of paraffin sec-
tions. Negri bodies were not present in
1,573, or 52.4 per cent. One hundred twenty-
seven, or 4.2 per cent, were unsatisfactory
for microscopic examination. The high
incidence, 43.4 per cent, of animal brains
which showed Negri bodies indicates that
rabies is a widespread disease in animals,
especially dogs, in this locality.

Our data indicate that rabies is increas-
ing in the animal population. In 1941, 18
per cent of all animal brains submitted were
positive for Negri bodies. This figure in-
creased to 39 per cent in 1942 and has
reached 50 per cent in the first 10 months
of 1943.

Denison and Dowling5 believe that there
is a rise in the incidence of rabies in dogs
in Birmingham, Alabama. This belief is
based on an increase in the percentage of
positive dog brains, and it is their opinion

Palik and Moss — Rabies

159

that this rise represents a deepening of the
animal reservoir of infection.

THE SPECIES OF ANIMAL CAUSING THE EXPOSURE
AND THE DEATHS FROM RABIES

Of the 4,146 patients who received anti-
rabies treatment 3,737, or 90 per cent, were
exposed to dogs (table 3). The seven

TABLE 3

TYPES OF SUSPECTED OR PROVED RABID ANIMALS

CAUSING EXPOSURE TO PATIENTS RECEIVING

ANTI-RABIES

TREATMENT

Species of

Patients

Number

Per

animal

treated

deaths

cent

Dog

3,739

(90

%)

7

0.18

Cat

293

( 7

%) 1

Cow

36 1

Rat

10

Squirrel

6

Rabbit

4

Hog

4

( 2

0%)

0

0.00

Human

3

Horse

3

Mule

2

Monkey

1

Raccoon

1

Not stated

44

( 1.0%)

Total

4,146

7

0.16

human deaths from rabies occurred in this
group, a mortality of 0.18 per cent. Seven
per cent of the suspected animals were cats
and 2 per cent included all other animals.
Three patients were given Pasteur treat-
ment following intimate exposure to a case
of human rabies during the several days
of illness. No statement of the species of
animal causing exposure was made in 44,
or 1 per cent, of the cases.

These data indicate that dogs account for
the great majority of all exposures for
which patients receive anti-rabies treat-
ment. Dogs are also largely responsible
for transmitting the disease to other ani-
mals both within and outside of their own
species.

In the past ten years in New Orleans
there have been 10 proved deaths from
rabies — four within the past six months.
All were victims of this disease as the result
of bites from stray dogs which were rabid.

THE INCIDENCE AND MORTALITY OF RABIES DUR-
ING THE TEN YEAR PERIOD FROM JANUARY
1934 TO OCTOBER 1943

The incidence of rabies in New Orleans
from January 1, 1934, through October 31,
1943, is shown in the following graph.

The lower line of this graph represents
the number of dog brains positive for Negri

TO

>

5

m

CO

o

X)

i —

m

J>

< J >

CD

OJ

>

i

CD

4*

CP

160

Palik and Moss — Rabies

bodies. The upper line represents the num-
ber of patients treated in the Pasteur Insti-
tute Clinic during the same period. The
crosses represent human deaths from
rabies. Two patients were not treated with
anti-rabies vaccine (encircled crosses in
1934 and 1937). One patient is included
through the courtesy of Dr. E. H. Lawson
of Baptist Hospital.

Nineteen thirty-seven is often referred
to as an epidemic year in New Orleans. As
a matter of fact the epidemic began late
in 1936, reached its peak in 1937, continued
through the first six months of 1938 and
bordered on the epidemic level for the last
six months of 1938. During the last 8
months of 1939, the epidemic recurred and
reached a high level in October. The long
duration and the recurrence of the epidemic
indicate that the control measures which
were instituted were inadequate.

INFLUENCE O'F INJURY BY PROVED RABID ANIMALS
OR BY STRAY ANIMALS ON MORTALITY

Three thousand two hundred and* sev-
enty-three, or 79 per cent of all the cases
treated, were exposed through bites or
iacerations (table 4). Of these, 1,580 were

TABLE 4

INFLUENCE OF INJURY ON MORTALITY FROM
RABIES IN TREATED CASES

Patients

treated

Exposed with injury to

; proved rabid animal. .. 1,580

Number

deaths

5

Per

cent

0.31

Exposed with injury to
unproved rabid animal

1,693

2

0.11

Subtotal

.3,273

7

0.21

Exposed without injury to
proved rabid animal

. 693

0

0.00

Exposed without injury to
unproved rabid animal. ..

.. 180

0

0.00

Subtotal

. 873

0

0.00

Total

.4,146

7

0.16

injured by a proved
among these patients

rabid

there

animal

were

and

five

deaths, a mortality of 0.31 per cent. One
thousand six hundred and ninety-three per-
sons were injured by stray animals in which
rabies was suspected but could not be
proved. Two patients in this group died
of the disease, a mortality of 0.11 per cent.
Only 873, or 21 per cent, of all the patients

treated were exposed without direct injury.
Of these, 693, or 16.7 per cent, were ex-
posed to a proved rabid animal and 180
were exposed to a stray animal. Among
the cases exposed without injury, there
were many children in whom the history
was suspected of being inaccurate, and some
patients in whom the exposure was of such
an intimate nature that treatment was
deemed necessary. There were no fatalities
among these patients. A total of seven
deaths from rabies, a mortality of 0.16 per
cent, occurred in the 4,146 cases receiving
anti-rabies treatment.

All of the deaths in our survey occurred
in individuals who were actually bitten by
rabid animals. This agrees with the rec-
ords from Alabama5 where, during 17 years,
injury by the teeth of rabid animals ac-
counted for all of the deaths from rabies.
The same findings prevailed in reports of
rabies, with the possible exception of one
case, during an 18 year period in Georgia.8

Fifty-four per cent of the treated pa-
tients were exposed to proved rabid ani-
mals. This indicates that there is a deep
reservoir of rabies virus among the animals
(chiefly dogs) in this community. The
unproved rabid animals represent strays,
usually dogs, in which it was impossible
to secure the brain for examination. It is
evident that rabies was present in consid-
erable concentration in these animals, since
two of the 1,693 patients injured by un-
proved rabid dogs died of rabies, a mor-
tality of 0.11 per cent.

INFLUENCE O.'" LOCATION OF THE INJURY ON THE
MORTALITY FROM RABIES

Injury to the head occurred in 354 pa-
tients, 8.5 per cent of the cases (table 5).

TABLE 5

INFLUENCE OF THE LOCATION OF THE INJURY ON
THE MORTALITY FROM RABIES*

Location

l’atients

treated

Number deaths l’er

cent

of injury

C. II.

McIC.3

c.

II. McIC.3 C. II.

McIC.3

Head

334

42,GS1

3

SOS 0.84

2.10

Arms

1,869

321,133

2

836 0.10

0.20

Trunk

111

31,012

0

33 0.00

0.10

Legs

1,364

351,636

2

584 0.15

0.10

Not stated

548

0

0.00

Total

4.146

746.462

7

2,351 0.10

0.31

""Including all races.

Palik and Moss — Rabies

161

Three deaths, a mortality of 0.54 per cent,
occurred in this group.

Injury to an upper extremity occurred
in 1,869 patients, 45.1 per cent of the cases.
Two deaths, a mortality of 0.10 per cent,
occurred in this group.

Injury to the trunk occurred in 111 pa-
tients, 2.7 per cent of the cases. There were
no deaths in this group.

Injury to a lower extremity occurred in
1,264 patients, 30.5 per cent of the cases.
Two deaths, or a mortality of 0.15 per cent,
occurred in this group.

The location of the injury was not re-
corded in 548 patients, 13.2 per cent of the
cases. No deaths occurred in this group.

These results are in general agreement
with those reported by McKendrick.3 In
a tabulation of 746,462 treated individuals
of all races, McKendrick3 reported that in
42,681 patients in whom injury occurred
to the head there were 898 deaths, a mor-
tality of 2.10 per cent. In 321,133 patients
in whom injury occurred to an upper ex-
tremity, there were 836 deaths, a mortality
of 0.26 per cent. In 31,012 patients in whom
injury occurred to the trunk, there were
33 deaths, a mortality of 0.10 per cent. In
351,636 patients in whom injury occurred
to a lower extremity, there were 584 deaths,
a mortality of 0.16 per cent.

The relative mortality among patients as
regards location of the injury in our series
agrees with that of McKendrick3 on one
main point, for example, that injuries to the
head are attended with a much higher mor-
tality rate from rabies than are injuries
elsewhere. The remainder of our tabula-
tion shows no significant difference in mor-
tality rate among persons bitten elsewhere
with the exception that no deaths occurred
following injury to the trunk. Our mor-
tality rates in patients injured elsewhere
are probably not statistically significant for
comparative purposes because of the small
number of fatalities in each group. Mc-
Kendrick’s3 review shows that injuries to
an upper extremity are associated with a
mortality rate which is approximately twice
that following injury to the trunk or lower

extremities. The significant fact, which
is evident in both reviews, is that injuries
to the head are attended with a much higher
mortality rate than are injuries elsewhere.

INFLUENCE OF INTERPOSITION OF CLOTHING ON
THE MORTALITY OF RABIES

Rabies virus was inoculated into the ex-
posed skin in 3,242, or 78.2 per cent, of the
patients treated (table 6). There were

TABLE 6

INFLUENCE OF INTERPOSITION OF CLOTHING ON
MORTALITY FROM RABIES

Type of

Patients

Number

Per

Exposure

treated

deaths

cent

Bare skin

3,242

7

0.21

Through clothing

857

0

0.00

Not stated

47

0

0.00

Total

4,146

7

0.16

seven deaths, a total mortality of 0.21 per
cent in this group. Eight hundred and
fifty-seven were exposed with the interpo-
sition of clothing. No deaths were re-
corded among these patients. No statement
relative to the presence or absence of cloth-
ing was made in 47 instances ; no fatalities
occurred in this group.

The interposition of clothing influences
the incidence of rabies following the bite of
a rabid animal to a considerable degree.
The virus is introduced directly into the
wound when the injury is inflicted to the
exposed skin. Clothing serves to remove
the saliva from the teeth of the animal
and so prevents the introduction into the
wound of an infecting dose, even though
the skin may be broken.

INFLUENCE OF THE RACE ON THE MORTALITY
OF RABIES

White patients comprised 3,441, or 83 per
cent, of the patients receiving anti-rabic
treatment (table 7). There were five

TABLE 7

INFLUENCE OF RACE ON MORTALITY FROM RABIES

Patients treated
C. H. McK.3

Number deaths . iPer
C. H. McK.3 C. II.

cent

McK.3

3,441

5

0.14

European

553,505

S54

0.15

Colored

Non-

European

705

o

. .. 0.28

476,285

2,659

0.56

Total

4,146

1,029,790

7

3,513 0.16

0.34

162

Palik and Moss — Rabies

deaths, a mortality of 0.14 per cent. Col-
ored patients comprised 705, or 17 per cent,
of the treated patients. There were two
deaths, a mortality of 0.28 per cent.

These results are in general agreement
with those of McKendrick.3 In a tabulation
of 1,011,790 treated individuals this author
showed that among 553,505 Europeans
there occurred 854 deaths, a mortality of

0.15 per cent; among 476,285 non-Euro-
peans there were 2,659 deaths, a mortality
of 0.56 per cent. These findings suggest
that race has a bearing upon the mortality
of rabies.

INFLUENCE OF INTERVAL BETWEEN EXPOSURE AND

INSTITUTION OF ANTI-RABIC TREATMENT ON
MORTALITY OF RABIES

Pasteur treatment was instituted in 2,620
patients, 63.2 per cent of the cases, within
four days following exposure to rabies
(table 8). Six deaths or a mortality of
0.22 per cent occurred in this group.

TABLE S

INFLUENCE OF TIME INTERVAL BETWEEN
EXPOSURE AND INSTITUTION OF ANTI-RABIES
TREATMENT ON MORTALITY FROM RABIES*

Days

Patients treated
C. H. McK.3

Number deaths
C. II. McK.3

Per cent
C. II. McK.3

0-4

5-7

8-14

Over 14

2,620

817

536

173

502,761

154,707

98,006

47,393

6 1,520

0 371

0 231

1(30 259

days)

0.22 0.30

0.00 0.23

0.00 0.23

0.57 0.54

Total

4,146

S02,867

7 2,381

0.16 0.29

♦Includin

g all

races.

Pasteur treatment was instituted within
a period of five to seven days following
exposure in 817 patients, 19.7 per cent of
the cases. There were no deaths in this
group.

Pasteur treatment was instituted within
a period of eight to 14 days following ex-
posure in 536 patients, 12.9 per cent of
the cases. There were no deaths in this
group.

Pasteur treatment was instituted more
than 14 days following exposure in 173
patients, 4.2 per cent of the cases. One
death, a mortality of 0.57 per cent, occurred
in this group.

The results of our tabulation coincide
with those of McKendrick3 with the excep-

tion that no deaths occurred in the cases of
our series where the institution of Pasteur
treatment was begun between 5 and 14 days
following the injury. This disparity may
be based on the small number of fatalities
in our series. These data suggest that de-
lay in institution of Pasteur treatment to
individuals of all races has no significant
effect upon the mortality from rabies until
more than two weeks have elapsed follow-
ing which the mortality rate becomes more
than doubled.

CONTROL OF RABIES

The control of rabies depends upon the
control of the dog population. The sys-
tematic and vigorous destruction of stray
dogs will eradicate the disease. The elimi-
nation of stray dogs, combined with the
control of pet dogs, is the one and only
effective control measure. All other meas-
ures are but adjuncts to this effective pro-
cedure.

SUMMARY

1. Four thousand, one hundred and
forty-six patients received Pasteur treat-
ment in the Pasteur Institute Clinic of
Charity Hospital during the period from
January 1, 1934, through October 31, 1943.

2. Of 3,003 animal brains submitted for
examination, 1,003, or 43.3 per cent, were
positive for rabies.

3. Stray dogs, which were unavailable
for examination, were responsible for ex-
posure to rabies in 45 per cent of the pa-
tients treated.

4. New Orleans experienced an epidemic
of rabies beginning in the latter part of
1936 and continuing until the latter part
of 1939.

5. The present epidemic began early in
1943 and has shown a higher human mor-
tality than the previous epidemic.

6. Dogs were responsible for the ex-
posure of 90 per cent of the patients treated
and for all of the seven deaths from rabies.

7. Actual injury by a proved rabid ani-
mal increases the mortality rate.

8. Injuries about the face, head or neck
are more dangerous than are injuries to
other parts of the body.

Pierce and Sako — Premature Infant Care

163

9. Injuries through clothing are less
dangerous than injuries inflicted through
the bare skin.

10. The mortality from rabies is greater
in negroes than in white patients.

11. Mortality from delay in instituting
treatment is not significantly increased
until two weeks following the injury.

12. Rabies can be controlled by control-
ling the dog population.

REFERENCES

1. Webster, L. T. : Rabies, The MacMillan Company,
New York, 1942.

2. Hutyra, F., and Marek, .T. : Special Pathology and
Therapeutics of the Diseases of Domestic Animals, Vol. 1,
Alexander Eger, Chicago, 1936.

3. McKendrick, A. G. : A Ninth Analytical Review of
Reports from (Pasteur Institutes on the Results of Anti-
rabies Treatment, Bull, of the Health Organisation of the
League of Nations, 9: No. 1, 31-78.

4. McCoy, G. W. : Personal Communication.

5. Denison, G. A., and Dowling, J. D. : Rabies in

Birmingham, Alabama. Human mortality as affected by
antirabies treatments, J. A. M. A., 113 :390, 1939.

6. VanRooyen, C. E., and Rhodes, M. B. : Virus Diseases
of Man, Oxford University Press, London : Humphrey Mil-
ford, 1940, page 54.

7. Charity Hospital Reports — 1903-1904.

8. Sellers, T. F. : Antirabie treatment, J. Med. Assn.
Georgia, 28:298, 1939.

O

CARE OF THE PREMATURE INFANT
AT CHARITY HOSPITAL

HAZEL PIERCE, R. N.*
and

WALLACE SAKO, M. D.*

New Orleans

All infants born before the thirty-sixth
week of gestation and weighing less than
2500 grams (5 pounds) or measuring less
than 48 cm. in length or unable to maintain
normal body temperature when exposed to
ordinary nursing conditions, usually require
premature care. The purpose of this com-
munication is to describe the nursing and
medical care these premature infants re-
ceive at the Charity Hospital of New
Orleans. The following factors will be
considered.

I. Physical set-up.

II. Equipment.

III. Nursing personnel.

IV. Aseptic nursing technic.

*From the Charity' Hospital of New Orleans and
the Department of Pediatrics, Louisiana State
University School of Medicine.

V. Management of the premature in-
fant.

VI. Investigation of home before dis-
charge.

VII. Follow-up care after discharge.

i. physical set-up

The premature unit is a separate nursery
which isolates the immature infants from
all other patients. The temperature of
the rooms in the unit is maintained at
78-82° F. The nursery is divided into two
sections with a separate personnel for each.
One section is for uninfected “clean” pre-
mature infants who are admitted directly
from the hospital delivery rooms. The other
section is for isolation purposes and re-
ceives the following:

1. All babies born in sections of the
hospital other than the delivery room, in-
cluding babies born on stretchers and in the
wards on the obstetrical floor.

2. All babies born outside the hospital.

3. All premature infants who become
infected while in the “clean” section.

A wall and two flanking hallways sepa-
rate these two sections. Overclothes and
coats are hung on hooks in these hallways.
Each section has a scrub room set up at the
nursery entrance with gowns and masks
available for all personnel entering the
nursery. A dressing room, a utility room,
and a formula room are located in each
section.

Small rooms adjoining the main “clean”
nursery are used as the observation quar-
ters where infants not responding to rou-
tine care properly are isolated for 48 hours.
The pediatrician, after examination and
observation during this time, decides upon
the proper disposition of the case :

1. Baby may be left in the “clean” nur-
sery.

2. General isolation.

3. Complete isolation.

In like manner, the isolation unit is
equipped with small rooms adjoining the
main nursery. These rooms are used for
complete isolation in which individual gown
technic is carried out.

164

Pierce and Sako — Premature Infant Care

II. EQUIPMENT

Some type of incubator or heated bed is
necessary for adequate care. The price of
incubators ranges from $15.00 to $500.00
and the choice of incubator depends largely
upon the amount of money the institution
feels justified in spending. However, pre-
mature care is not solved by the purchase
of expensive incubators. It is far more ad-
visable to have less expensive incubators
and better nursing personnel than to have
expensive incubators and too few nurses to
operate them. A box affording protection
of the infant from the environment and
heated with a shielded electric light bulb
will suffice. This should be so constructed
that the infant can be cared for without
removing it from the bed.

Other equipment needed are :

1. A gram scale which weighs accu-
rately.

2. Individual bath basins which should
be sterilized daily.

3. Individual thermometers to lessen
cross infection.

4. Bassinettes in which the baby can be
placed when incubators are no longer nec-
essary.

5. Wall thermometers for checking room
temperature.

6. Standard nursery equipment.

7. Diaper and linen hamper.

8. Running water with knee, foot, or
elbow control, in every room — the more ac-
cessible the running water, the more apt it
is to be used.

9. Plenty of soap and a sufficient num-
ber of paper towels.

10. Incubators and bassinettes should
not be placed adjacent to each other. Suf-
ficient space between them will prevent
linen from one crib coming in contact with
the baby or linen in the next bassinette.

III. NURSING rERSONNEL,

It is important to remember that no set-
up, however good, will be effective unless
there is a sufficient number of nurses. The
shortage of nursing personnel is one im-
portant reason why newborn babies receive
inadequate nursing care, and why there are

epidemics of diarrhea, impetigo and other
infections in nurseries. There should be a
responsible graduate nurse in charge at all
times.

There should be four graduate nurses
especially trained for this work. This al-
lows for a head nurse during the day, eve-
ning, and night. Te fourth graduate nurse
would assist the day supervisor and relieve
the evening and night supervisor on their
days off duty. This insures graduate super-
vision in the nursery at all times.

The other help in the nursery are student
nurses and nursery maids. The graduate
nurse teaches and supervises those work-
ing with her. There should be at least one
nurse to every four to six babies. We can-
not expect one nurse to care for fifteen to
twenty babies and use aseptic technic.

It is the nurse’s responsibility to give
special attention to each baby under her
care and to report every pertinent finding
to the pediatrician in charge. She should
know the technic used, the emergency treat-
ments, the methods used in maintenance of
normal body temperature, the methods of
feeding, and be able to recognize clinical
symptoms and pathologic manifestations.

It is the supervisor’s responsibility to
establish a simple routine which can be
carried out by everyone in the nursery.
Procedures should be carried out in the
designated method. In nurseries in which
each graduate nurse attempts to carry out
her own method, the result is usually a
complete lack of technic and routine.

The supervisor or her assistant should
see that all nurses are taught the proce-
dures accurately. These should be demon-
strated, and the demonstration returned
under close supervision before the student
or helper is allowed to do the work. Feed-
ing, diapering, putting nipples on bottles,
making beds, anything that the new nurse
is to do should first be demonstrated. And
it should be pointed out that the most
minute detail in technic is important.

The nurse must be alert, observing, en-
thusiastic and above all “premature con-
scious” at all times. The routine must be
carried out consistently during the entire

Pierce and Sako — Premature Infant Care

165

24 hours. At no time can there be any
relaxing in good technic, nor in intelligent
observation and efficient nursing care.

IV. ASEPTIC NURSING TECHNIC

Premature and immature infants are
very susceptible to infection. Therefore, it
is important to observe carefully the follow-
ing factors :

1. Scrub hands and arms to the elbows
on entering the nursery.

2. Wash hands with soap and running
water :

a. Between handling babies.

b. After diapering.

c. Before feeding.

d. After using a handkerchief or ad-
justing a mask.

e. After handling charts.

f. After using the telephone.

g. After moving screens or other
equipment.

3. Feeding and diapering (two separate
procedures) . Have all soiled linen removed
from nursery before feedings are brought
into the room.

4. Have scale on rolling table and place
it beside each infant’s bed as needed. Drape
scale properly, covering the sides and ends
of platform.

5. Bathe each baby in its own bed.

6. Hold soiled or contaminated linen
away from gown.

7. Drape treatment table for each baby.

8. Keep sterile containers securely cov-
ered at all times.

9. Keep forcep jars filled.

10. Hold baby, either on lap or in bed,
while feeding and protect nipple from con-
tamination.

11. Cover feedings when bringing them
from formula room to nursery and during
feeding period.

12. Nipple bottles as needed.

13. Place empty bottle and nipple in pan
containing soap solution and water pro-
vided for such.

14. Keep all equipment from touching the
floor as it is grossly contaminated at all
times.

15. In bathing of handling the baby, care
is taken to consider the upper part of the

baby and bed as clean and the lower part
contaminated. The nurse should not han-
dle the upper part of the baby or bed after
touching the lower part without first wash-
ing her hands.

A. MASK AND GOWN TECHNIC

Masks and gowns are worn at all times
by doctors, nurses, helpers, and technicians
while in the nursery. An adequate supply
of gowns and masks is kept in the scrub
room.

Gowns are to be changed as frequently
as necessary; that is:

1. At the end of a work period.

2. After contamination by:

a. Vomitus.

b. Feces.

3. To go. from Isolation to Clean
Nursery.

4. At any time gown becomes contam-
inated.

Masks should be worn well tip over the
mouth and nose. They should be changed
as soon as they become soiled or damp.
Masks are totally ineffective with colds, so
the individual with a cold should not go
into the nursery. The central section of a
mask is highly contaminated and should
not be touched at any time. If it must be
adjusted, grasp it by the ends, not the part
over the nose and mouth, then wash hands.

B. THE HAIR

The hair is teeming with bacteria ; there-
fore, the head should be covered with a cap
of net or domestic. The hair should not be
touched at any time while caring for a
patient.

c. ISOLATION

At the first symptom of infection the
infant should be placed in an observation
room, and kept there until examined by the
doctor. If advised, transfer infant to prop-
er room and carry out routine technic for
that particular condition.

V. MANAGEMENT OF THE PREMATURE INFANT

In order to conserve time and space the
medical and nursing management of the
premature infant is condensed to outline
form.

A. Immediate care on admission:

1. Be prepared to receive baby.

166

Pierce and Sako — Premature Infant Care

2. Avoid chilling.

a. Wrap in pre- warmed pack made of
sterile absorbent cotton and two layers of
gauze, or

b. Place in pre-warmed bassinet with
head dependent, or

c. Place in incubator at temperature
of 98° F.

3. Trained nurse does the following:

a. Aspirate mucus.

b. C02 and 0, inhalations every 30
minutes x 6.

c. Place under oxygen tent if indi-
cated.

d. Administer vitamin K 1 mg. (H).

e. Administer 1 per cent AgN03 in

eyes.

f. Observe cord for bleeding.

g. Record baby’s temperature.

h. Weigh, if conditions permit (with
clothing and later deduct).

4. Strict asepsis.

a. Sterile gowns, masks, equipment,
scrubbing of hands.

B. Maintenance of body heat.

1. Keep infant’s temperature as constant
as possible (around 99° F.) with aid of in-
cubator or warm water bottles, tempera-
ture of water bottles not to exceed 110° F.
Remember, baby seldom survives if tem-
perature is allowed to go down to 95° or
lower.

2. Constant room temperature 78-82° F.

3. Regulate incubator temperature every
two hours for first 24 hours, then every
four hours subsequently. Adjust incubator
temperature depending on infant’s tem-
perature.

4. Record rectal temperature of baby
every four hours or oftener until stabilized.

5. Constant relative humidity, room at
55 per cent, incubator at 65 per cent.

6. Avoid drafts in nursery.

7. Continue premature care until in-
fant’s temperature is stable under ordinary
room conditions.

C. Conservation of energy.

1. Do not bathe for first 10 days.

2. Handle as little as possible.

3. Feed small or weak infants by gavage
to prevent exhaustion.

4. Do not remove from bed or incubator
unless absolutely necessary.

D. Treatment of asphyxia. Administer
in incubator.

1. Remove mucus from respiratory pas-
sages.

2. Dependent drainage of secretions and
mucus.

3. Gradual increase of feeding depend-
ing on gastric capacity.

4. Administration of oxygen (100 per
cent) or oxygen (95 per cent) +C02 5 per
cent.

a. Funnel.

b. Catheter.

c. Tent.

d. E & J inhalator.

e. Intratracheal insufflation.

5. Artificial respiration. Exercise gen-
tleness.

6. Mechanical resuscitation.

a. Drinker respirator of very little

value.

b. E & J resuscitator safer.

E. Stimulation.

1. Irritation of afferent nerves.

a. Rub skin.

b. Gentle thumping of soles of feet.

c. Ether drops to feet.

2. Chemical.

a. Epinephine 1:1000 solution, M i
(H) q. 1 hr. Increase dose and lengthen
interval later.

b. Coramine, caffeine, alpha-lobeline
M iii (H).

c. CO, (5- 10 per cent) in oxygen by
inhalations.

3. Intramuscular whole blood, 10 c. c.

F. Intracranial hemorrhage.

1. Vitamin K — intramuscularly 1 mg. q.
2 hrs. x 6.

2. Whole blood (10-30 c. c.) intramus-
cularly or subcutaneously.

3. Avoid epinephine.

G. Prevention of respiratory and skin
infections.

1. Permit no visitors in nursery.

2. Exclude all individuals with “colds”
from nursery.

Pierce and Sako — Premature Infant Care

167

3. Personnel in attendance must wear
sterile gown and mask and scrub hands
before and after handling baby.

4. Remove infants with infection into
septic room. Do not return them to clean
nursery.

5. All prematures admitted from outside
should be considered potentially infected.

6. In septic room, attendants should
scrub hands, change gowns, and use sep-
arate equipment for each infant.

7. No bath or oil first ten days of life.

a. Wipe blood and meconium off with
sterile water.

b. Clean buttocks only.

H. Prevention of diarrhea.

I. Aseptic technic.

\

2. Breast milk at all times if obtainable.
If not, lactic acid milk is desirable.

3. Sterile formula, water, and equip-
ment.

4. All diarrhea should be isolated.

5. Diarrhea is one of the most common
causes of death in premature infants.
Therefore, it is of utmost importance to
check the amount, the color and the con-
sistency of each stool throughout the 24
hours for each day. At the first abnor-
mality noted, the infant should be starved
and given only weak tea and water for a
period of six to twelve hours during which
time a stool culture is made. If the diar-
rhea is due to over-feeding, the stools will
be normal by that time. If not, the pedia-
trician will then begin treatment.

6. A letter system is used in recording
stools. They are recorded in the following
order: (1) amount; (2) color; (3) con-
sistency— thus : L.Y.S. for large yellow
soft. (It is not necessary to chart “S” for
stools). This saves time and space and
tends to result in more stools being recorded
than would be otherwise.

I. Weighing.

Weigh with clothes on. W’hen changed,
deduct weight of clothing.

J. Clothing.

It is imperative to remember that the
preservation of body heat must be begun
immediately after birth, in fact the baby

should be received in a warm blanket and
immediately transferred to the nursery.

1. Temporary clothes:

If the infant is under three pounds, do
not dress, wrap in soft, warm blanket or
cotton and place in heated bed or incubator.

2. Permanent clothes :

Bath packs are put up and sterilized for
the morning care.

These packs include:

a. Diaper — folded rectangularly.

b. Shirt or short gown.

c. Foot wrapper.

d. Abdominal binders are kept in a
sterile container in nursery. Keep infant
covered lightly for warmth, but not suffi-
cient to restrict movement of arms and
legs.

K. Oxygen therapy.

Oxygen is, in the care of premature in-
fants, as important as breast milk. The
frequent need of oxygen therapy is the
main reason why premature infants should
be hospitalized. A supply of oxygen should
be in every nursery so that it will be avail-
able for emergencies.

In the premature its use is indicated:

1. For all babies under 1500 grams of
body weight.

2. For any baby where cyanosis is noted.

3. For any baby whose prematurity is
either caused by toxemia or placenta
praevia.

4. For pneumonia.

5. For cesarean section deliveries.

6. For asphyxia.

7. After a long difficult labor.

L. Method of feeding. Given without
removing infant from incubator.

1. Small premature (2000 gm. or less).
Use No. 10-12 French catheter.

a. Measure distance from bridge of
nose to ensiform cartilage and mark this
point with AgN03.

b. Moisten sterile catheter. Insert to
AgNOg mark.

c. Note breathing. Milk air from
tube, kink tube, pour milk slowly.

d. Support baby in semi-recumbent
position.

168

Pierce and Sako — Premature Infant Care

e. Kink catheter and remove gently.
Do not permit milk to escape from catheter
when removing it.

f. Have mother express breasts every
four hours and bring milk to hospital daily.

g. Put baby to breast when it can
maintain normal temperature.

h. Artificial formula.

(1) y2 skimmed milk -f- 2 per cent
casec -f- 5 per cent sugar, or

(2) Lactic acid milk :

Evaporated milk 400 c. c.
Water 400 c. c.

Sugar or Karo 4 tablespoon-
fuls.

Boil water, cool, then add 6
c. c. lactic acid.

Combine with milk.

2. Larger prematures (over 2000 grams)

a. Use medicine dropper with tip
protected by soft rubber tubing or

b. Bottle with small rubber nipple.

c. If unable to feed by bottle or drop-
per use catheter method.

M. Guide for feeding premature infants.

No milk, water or sugar solution for 12
hours following birth.

Reduce feedings if they are accompanied
by vomiting or cyanosis.

After two weeks, change feeding accord-
ing to indications.

Give 50 mg. ascorbic acid twice daily,
corrects inability to decarboxylate aromatic
amino-acids beyond organic acid stage.

Vitamins A (2500 units) and D (400
units) concentrates added at two weeks.

Iron added at two and a half weeks.
FeSCb or iron ammonium citrate 10 grains
daily.

For maintenance need about 90 calories
per Kg. daily.

For growth need about 125 calories per
Kg. daily.

Need about 150 c. c. water per Kg. daily.

Lose 10-20 calories per Kg. through loss
of fat in stool.

Rule :

1. Amount of milk to be fed per feed-
ing = (age in days -f 1) X wt. in lbs.

2. Amount of water to be fed per feed-
ing = (age in days -f 2) X wt. in lbs.

Under

1250 G.

1500-2000 G.

2000 G.

Under

1250 G.

1500-2000 G.

Over

1250 G.

to

3. 3-4. 4 lb.

4.4 lb.

1250 G.

to

3. 3-4. 4 lb.

2000 G.

or

1500 G.

or

1500 G.

4.4 lb.

2.75 lb.

or

2.75 lb.

or

2.75 lb.

2.75 lb.

to

to

3.3 lb.

3.3 lb.

Age in

hours

or days

c. c. sterile water or 5% sugar in saline

c.c. milk given each 3 hours

solution

given every 3 hours.

0-12 hr.

0

0

0

0

0

0

0

0

12-24 hrs.

0

0

0

0

5

10

15

20

2

5

10

15

20

7

12

18

24

3

6

11

17

23

9

14

20

26

4

7

12

19

26

12

18

25

30

5

8

14

21

29

15

22

30

30

6]

Subsequent daily increase

Give every 3 hours between milk

7

feedings.

Increase amount as

8

indicated.

9

i n

»

1-2 c.c.

2 c.c.

2-3 c.c.

3-4 c.c.

1 1

Begin to

omit water c

r lactose

12

feedings g

radually.

13

Feeding Guide

Pierce and Sako — Premature Infant Care

169

N. Breast milk.

Breast milk is the most desirable food
for any newborn. Every effort is made to
obtain it. As there is no breast milk sta-
tion available, the supply is mainly from
the maternity wards in the hospital, while
the rest is obtained from the mothers who
have gone home. Due to the fact that the
breast milk is not collected under aseptic
technic, it is necessary to boil it 3 min-
utes before using it. Since the breast milk
supply is inadequate, the larger and
stronger infants are started and maintained
on an evaporated milk formula.

A sufficient number of nurses should
always be in the nursery to feed the in-
fants properly. All weak or small prema-
ture infants should be fed by gavage for
the first three days and if the baby is very
small it may be necessary to continue this
method from six weeks to two months.

Small infants with a well developed suck-
ing reflex may be fed by a small nipple —
this nipple may be made by puncturing one
hole in a medicine dropper top. This type
of nipple should be used for all infants
under four pounds. Then they may be fed
by the ordinary nipple.

Gavage feedings are indicated under the
following conditions:

1. Small prematures or those with poor
sucking reflex.

2. A marked increase in cyanosis when
the baby attempts to swallow.

3. Pneumonia.

4. Marked dehydration may necessitate
gavaging the baby for a period of 24 to
48 hours.

5. Deformities of mouth or throat.

All prematures should be fed every three
hours. Water or 5 per cent glucose in saline
should always be given between feedings to
prevent dehydration. Minimum feedings
prevent diarrhea and to a large extent vom-
iting. Feedings should be given slowly,
bubbling the infant two or three times dur-
ing the course of feeding and again at the
end of the feeding. If the baby vomits or
takes its feeding poorly, half of its feeding
should be given and the baby then allowed

to rest 10 or 15 minutes. The remainder
is then given or fed by gavage..

Larger prematures are supported on the
nurse’s lap with the head supported by the
hand, facing the nurse. This prevents hold-
ing the infant against the nurse’s gown, and
it also allows closer observation for signs
of cyanosis. To bubble the infant, merely
roll it to the side and gently massage the
back in an upward motion.

It is well to give C02 and 02 inhalations
to listless infants before feedings as a
stimulant.

VI. INVESTIGATION OP HOME BEFORE DISCHARGE

A. A nurse from the nursery visits the
mother in the obstetrical ward. She finds
out the number of children in the family
and whether previous children had been
breast-fed. She attempts to win the confi-
dence of the mother and encourages the
mother to keep up her supply of breast milk
until the baby can go home.

B. When the mother goes home she is
brought to the nursery and is shown her
baby. Again the nursery nurse tries to im-
press the mother with the importance of
pumping her breast, and if possible, send-
ing the breast milk to the hospital for the
baby. (This milk is sterilized by the dieti-
cian before using.) She is then instructed
to check on the baby’s condition.

C. Within the first week after the baby
is admitted to the nursery, the Department
of Child Welfare is notified, and asked to
check home conditions and the mother’s
ability to care for her baby. A public health
nurse then visits the home and obtains the
following information:

1. Number in family.

2. Number of rooms in house.

3. Type of heating.

4. Utensils for making formula.

5. Mother’s ability to follow instructions.

6. Suggested date for discharge.

The nurse instructs the mother as to the
clothes and equipment needed for the baby.
If the home is clean and the mother intelli-
gent enough to follow instructions, she is
again instructed in the technic of breast
expression and to send breast milk to the

Table 1

Premature Mortality Rate for 1941, 1942, 1943

170

Pierce and Sako — Premature Infant Care

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hospital. It is usually considered better to
have the mother send breast milk to the
hospital, although the home may be unde-
sirable, since a breast fed baby would have
a better chance for survival in an unclean
home than would one on a carelessly pre-
pared formula.

D. If the home conditions are satisfac-
tory, the baby is then discharged at six
pounds or thereabouts. If home conditions
are unsatisfactory, the case is referred to
Social Service and adjustments are made,
if possible. Sometimes it is necessary to
place an infant in a foster home if :

1. Tuberculosis exists in the home.

2. Extreme poverty.

3. Mother is not capable of caring for
child.

E. At the time of discharge the mother
is taught how to bathe, dress and feed the
infant. She is given written and oral in-
structions for making the formula, or if
baby is to be breast fed, she is allowed to
feed the baby at least once before leaving
the hospital. She is given a clinic appoint-
ment in two weeks, and instructed to bring
the baby back to the hospital or consult a
private physician immediately if it becomes
ill, or manifests such symptoms as:

1. Vomiting.

2. Diarrhea.

3. Rash.

4. Loss of weight.

5. Upper respiratory infection.

F. Finally the mother is invited to bring
the baby back to the nursery when she
comes to the clinic. This pleases the mother,
if she is at all interested, and it gives the
nurses an opportunity to learn whether or
not the baby is being cared for properly.

VII. HOME 'CARE

A. The day after leaving the hospital,
a visiting nurse calls on the mother. Then
weekly visits, or as indicated, are made.

B. Visiting nurse checks the following:

1. General condition of home.

2. Attitude of mother and father.

3. Room — cleanliness, proper heating,
adequacy of isolation from other adults and
children.

Eddy — March Fracture

171

5. Examination of infant :

a. Weight, temperature.

b. State of nutrition.

c. Character of respiration.

d. Condition of mouth, skin, buttocks.

e. Presence of anemia, icterus, etc.

6. Observe mother bathe and feed child.

a. Check technic, temperature of bath
water, soap used, etc.

b. Perfect mother’s technic of breast
leeding, breast expression and preparation
of formula.

7. See that mother gives child :

a. Cod liver oil, two teaspoonfuls
daily or concentrate 45 drops daily.

b. Orange juice, two ounces daily or
50 mg. ascorbic acid.

c. Iron — 10 mg. daily.

9. Answer other questions which mother
may desire to ask.

CONCLUSION

Since instituting a definite program for
the care of the premature infant as out-
lined above, the premature mortality rate
has dropped from 80 per cent in 1937 to
27 per cent in 1943. The mortality rate
according to weight of these immature
young infants for the past three years is
tabulated below.

o

MARCH FRACTURE IN INDUSTRY

JAMES H. EDDY, JR., M. D.f
Shreveport

In this war as in the last one there have
been reported a large number of patients
presenting the injury known as march frac-
ture. While this fracture has been described
since 1855, only recently has it received
much publicity. This sudden interest stems
from its relatively frequent occurrence
among soldiers during intensive training.
This is well brought out in recent papers
by Bush,1 Krause,2 Flavell,3 Moore and
Bracher,4 and Barns.5 Its rare occurrence
in civilian life accounts for its being so little
discussed outside of military hospitals. Pa-
pers by Newell,0 Stammers,7 and Drum-

fFrom the Medical Department of the Louisiana
Ordnance Plant, Shreveport, La.

mond8 describing the occurrence of this
injury in medical personnel are interesting
and are not unlike the cases occurring here
in that no long march was involved.

The discovery of three cases of this frac-
ture among women employees of a shell
loading plant during a period of only eight-
een months prompted me to bring this in-
jury to the attention of industrial physi-
cians.

March fracture, or fatigue fracture of
the metatarsal, is a term applied to frac-
tures of the metatarsals occurring without
direct trauma. Bohler9 speaks of these as
fractures due to indirect injury. The frac-
ture usually develops at the end of a long
march, or as in our cases, after work in-
volving long hours of walking or standing
on concrete floors. The second or third
metatarsal is the bone most commonly af-
fected.

The cause of these fractures is diffi-
cult to understand. Just why a foot that
has borne weight throughout the individ-
ual’s life should suddenly weaken and break
is not clear. The theory of Brandt10 as
quoted by Krause11 seems most reasonable.
To use Krause’s own words: “These frac-
trues are the result of rhythmically re-
peated, subthreshold mechanical insults, act-
ilng by summation, to a point beyond the
capacity of the bone to bear stress.”

The patients seen here have all stated
that while at work they noticed pain over
the dorsum of the foot in the metatarsal
region. There was no sudden acute pain
but more of a gradual awareness of sore-
ness in the foot. The pain was especially
noticeable when bearing weight on the foot.
In no case did the patient present herself
for examination before several days after
the onset of pain. Because no injury can
be remembered, the patient expects the pain
to disappear and goes about her duties until
she becomes too uncomfortable to continue.
As is brought out in most papers on march
fracture, all of these patients had been en-
gaged in sedentary occupations prior to in-
jury. Examination reveals considerable
swelling over the dorsum of the foot with
tenderness over the metatarsal region.

172

Eddy — March Fracture

There is acute tenderness over the site of
fracture and pressure on the head of the
involved bone causes pain. A patient pre-
senting these findings should be suspected
of having march fracture and x-ray study
is indicated.

The x-ray appearance is characteristic
and will vary according to the length of
time that has elapsed since the onset of the
condition. In the early stages a fine hair-
line fracture will be seen, provided the x-ray
technic is perfect. In order to show these
fractures, the use of cardboard holders with
no-screen film cannot be too strongly rec-
ommended. Fig. 1 shows a late first stage
with early fuzzy callus just visible at the
sides of the fracture line. After two to
three weeks there may be some light callus
formation about the site of fracture,
through which the fracture line can be seen
as is shown in fig. 2. The callus then
gradually increases in density and the frac-
ture line disappears. These lesions tend to
produce rather abundant callus in spite of
adequate immobilization. This is illustrated
in fig. 3. The late appearance of the x-ray
film is only that of thickened cortex.

Treatment consists of immobilization in
a boot cast fitted with a walking iron. The
cast is worn about six weeks and x-ray ex-
amination should show firm callus before

Fig. l

Fig. 2

the patient is allowed to walk on the foot.
With a properly fitted cast these employees
are able to continue their work.

As is true in all injuries occurring at
work, the question of compensability arises.
In this type of case the problem is extremely
difficult as it does not fulfill the require-
ments of an accident. In this state, how-
ever, the compensation act provides for the
payment of compensation in all injuries re-
ceived by an “Employee in performing serv-

Fig. 3

Loomis — Fracture of Patella

173

ices arising out of and incidental to his em-
ployment.” Under this interpretation of the
law it has been advised that these cases be
accepted under the compensation act.

CASE No. 1

Mrs. B. H., a 44 year old white housewife, came
to the clinic on December 14, 1943 and stated that
her left foot first became painful about two weeks
previously and that the pain had gradually become
worse. She had been employed as a munitions
handler for several months prior to which she had
done only house work. Her work required standing
throughout an eight hour shift with the exception
of about 15 minutes at lunch time. It was also
necessary to walk about 500 yards to her work
from the dressing rooms. The walk was repeated
at lunch time. It was during one of these walks
that she first noticed pain. Examination showed
edema of the dorsum of the left foot with tender-
ness over the metatarsal area. The tenderness was
acute over the lower end of the second metatarsal.
Pressure on the head of this bone produced much
pain. The x-ray film is shown in figure 1. She
was treated by the application of a boot cast fitted
with a walking iron and was able to get about
fairly well. Her later course is illustrated in fig-
ures 2 and 3. She has had no further disability
and is back at her old job.

CASE No. 2

Mrs. J. G'., a 30 year old white woman who is
the mother of four children, came to the clinic on
June 18, 1943 and stated that eleven days pre-
viously she began having swelling and aching in
her left foot. She had continued at work but the
pain had become gradually more severe. This pa-
tient had been at work for about six months prior
to which she had done only house work. Her work
required long hours of walking and standing on
concrete floors. Examination of the foot revealed
edema of the dorsum that extended up to the ankle.
There was some tenderness of most of the foot but
this was severe over the middle of the third meta-
tarsal. Pressure on the head of that bone caused
much pain. X-ray revealed a fine fracture line in
the third metatarsal that appeared incomplete. She
was treated by immobilization in a boot cast fitted
with a walking iron. Later x-ray studies showed
the typical fusiform callus. She returned to her
job and has had no other disability.

CASE No. .3

Miss R. H., a 23 year old white girl, reported
to the hospital on June 15, 1943 complaining that
she had had pain in her left foot for two days. On
June 13 she had noticed that her left foot was
swollen and was becoming increasingly painful. She
had been at work for one year, during which time
she was required to walk the greatest part of her
eight hour shift. The floors of the building were

concrete. Before working at this plant she had
been a waitress in a cafeteria. Examination
showed edema of the dorsum of the left foot with
tenderness over the second metatarsal. X-ray
showed a fine, incomplete fracture of the second
metatarsal. A boot cast fitted with a walking iron
was applied and the patient was able to be up and
about. Later x-rays were similar to those shown
in Case 1. She has had no further disability.

REFERENCES

1. Bush, Leonard F. : March foot (march fracture) : Its
early diagnosis and treatment, Army Med. Bull., 08 : 126,
1043.

2. Krause, George R. : March fracture, Radiology, 38 :
473, 1942.

3. Flavell, Geoffrey : March fracture. A series of 15
cases from the R. A. F., Lancet, 245 :66, 1943.

4. Moore, (Prentice L., and Bracher, Allen N. : March
fracture. Report of three cases, War Med., 1 :50, 1941.

5. Barns, II. II. Fouracre : March fracture of the meta-
tarsal bones, Brit. M. J., 2 :608, 1943.

6. Newell, Cecil E. : March foot : A personal experience,
South. Surg., 9:169, 1940.

7. Stammers, F. A. R. : March fracture — pied force,
Brit. M. J., 1 :295, 1940.

8. Drummond, R. : March fracture. Report on case in-
volving both feet, Brit. M. J., 2:413, 1940.

9. Bdhler, Lorenz : The Treatment of Fractures, ed. 4,
Baltimore, William Wood & Co., 1935, p. 491.

10. Brandt, George: Ergebn d. Chir. u. Orthop., 33:1,
1941. Abst. in Year Book of Radiology, 1941, p. 35.

11. Krause, George R. : March Fracture, W'ar Medicine,
New York, F. Hubner & Co., 1942, p. 325.

O

FRACTURE OF THE PATELLA-
ANALYSIS OF 150 CASES AT
CHARITY HOSPITAL

LYON K. LOOMIS, M. D.f

New Orleans

ANATOMY

A proper understanding of patellar frac-
tures is based upon a clear conception of
the anatomy of the patella and its articu-
lation with the femur.

The patella is a sesamoid bone which usu-
ally ossifies from one center and makes its
appearance radiographically about the third
or fourth year of life. It differs from other
sesamoid bones by its large size and by its
location on the angle of extension rather
than the angle of flexion of the adjacent
joint. As a projection of spongy bone in
front of the femoral condyles, it protects
the knee joint by serving as the first line
of defense to trauma inflicted upon the an-
terior aspect of the knee.

fFrom the Department of Orthopedics, School of
Medicine of Louisiana State University, and Char-
ity Hospital, New Orleans.

174

LOOMIS — Fracture of Patella

The patella glides upon the trochlear sur-
faces of the femoral condyles as the knee is
flexed or extended and increases the pull
of the quadriceps group on the tibia by in-
creasing the angle of insertion of the patel-
lar ligament. When the knee is straight,
only the lower third of the patella articu-
lates with the femur and in this position
the patella can be moved from side to side.
In acute flexion the opposite is true; the
upper third of the patella is in contact with
the femur and the patella is fixed or im-
mobile. In semi-flexion the patella is most
susceptible to fracture. In this position
only the middle third of the patella is in
contact with the femur, the upper and lower
thirds being free.2 The femur thus serves
as a fulcrum over which the patella may be
broken as one might break a stick of wood
over the edge of a table.

AGE DISTRIBUTION

V.

nine years of age or over ninety years of
age, and the highest percentage of frac-
tures occurred between thirty and forty
years of age (fig. 1).

METHODS OF TREATMENT

INCIDENCE

A general study of 150 cases of fracture
of the patella which were treated at Char-
ity Hospital of Louisiana from 1933 to 1943
reveals a predominance of fracture in males
as compared with females and a predomi-
nance in the white race as compared with
the colored (table 1) . Contrary to the com-

A study of the methods of treatment dis-
closes the fact that 29 per cent (43 cases)
were treated conservatively with a high leg
plaster cast only, while 71 per cent (107
cases) were treated by an open procedure
(table 2) . The most popular procedure was

TABLE 2

METHODS OF TREATMENT — 150 CASES

TABLE I

INCIDENCE — 150 CASES

Per cent

1. Sex

a. Male 66

b. Female 34

2. Race

a. White 71

b. Colored 29

3 Mechanism of injury

a. Direct 92

(1) Fall 45

(2) Dashboard 41

(3) Miscellaneous 14

b. Indirect 8

mon opinion that most fractures occur from
indirect muscular violence, 92 per cent of
the fractures in this series occurred from
direct injury, and of this group 41 per cent
were caused by the knee striking the dash-
board in auto accidents. On the other hand,
indirect violence accounted for only 8 per
cent of the fractures. As for age distribu-
tion, no fractures occurred in patients under

Conservative (high leg Plaster of Paris cast) —
29% (43 cases)

Operative — 71% (107 cases)

Per cent

Iron wire 34

Unspecified type of wire 19

Patellectomy 17

Crochet cotton 10

Silver wire 5

Kangaroo tendon 3

Chromic catgut No. 3 3

Stainless steel wire 1

Unspecified material , 4

Operative record lost 4

open reduction and internal fixation with
iron wire. During the past five years pa-
tellectomy has been popularized and in this
study 17 per cent of the cases were treated
in this manner. During the past three
years crochet cotton has been used as an in-
ternal fixative in cases where a smooth ar-
ticular surface could be anticipated after
open reduction. Ten per cent of the cases
were fixed with this material (fig. 2). Sil-

Loomis — Fracture of Patella

175

Fig. 2 — A proper technic of repair is essential (reprinted
by courtesy of Surgery, Vol. 15, No. 4, April, 1944). (a)

Slightly curved transverse incision, (b) double strand No.
10 crochet cotton loop and two anterior sutures of crochet

cotton, (c) sagittal section showing loop and anterior
suture through patella. (d) Patella is repaired with
crochet cotton and capsule closed with interrupted sutures
of quilting cotton.

ver wire was used in 5 per cent of the cases.
Less popular internal fixatives were kanga-
roo tendon, No. 3 chromic catgut and stain-
less steel wire.

COMPARISON OF MATERIALS COMMONLY USED

Stovepipe and florist wires are both iron
alloy wires composed of ten different metal-
lic elements (table 3). Stovepipe wire has

TABLE 3

COMPARISON OF MATERIALS

Size* Tensile

Material (Diameter) Strength

Stovepipe Wire .0451 101 lbs.

Florist Wire .0268 41 lbs.

Silver Wire .0181 7 lbs.

Crochet Cotton #10 .0177 11.3 lbs.

*Size expressed in inches.

a diameter of .0451 inches and has a tensile
strength of 101 pounds. Florist wire has
a diameter of .0268 inches and has a ten-

Composition
Fe, Mn, Cr, Mg, Cu,

Ca, Ti, Al, Zn, Si

Same

Ag, Mn, Fe, Mg, Cu,

Ca, Pb, Sn, Zn, Si

Cellulose 91.00%
H20 8.00

Wax .35

Pectic matter .53
Mineral matter .12

sile strength of 41 pounds. As demonstrated
by Venable and Stuck,5 the number of
metals composing an alloy increases its bat-
tery action or electrolysis. Such electrolysis
is undesirable not only because it weak-
ens the wire but also because disintegration
of the wire increases tissue reaction. The
value of a nonelectrolytic material was rec-
ognized by Bohler who advocated the use of
heavy silk many years ago.1

The silver wire commonly used in fixa-
tion is composed of ten metals and has a
diameter of .0181 inches and a tensile

strength of only seven pounds. An added
disadvantage of silver wire is that it
stretches about one-third of its initial
length before breaking.

The brand of crochet cotton used has a
diameter of .0177 inches and a tensile

strength of 11. .3 pounds. It is 91 per cent
cellulose, the remaining content being prac-
tically physiologic with the body.4

176

Gaines — Central Field Studies

SUMMARY

As is frequently the case in a study in-
volving many cases, it was impossible to
get an adequate follow-up on all of the pa-
tients treated. However, 52 of the cases
had sufficient follow-up to permit certain
observations upon the different common
open procedures (table 4).

TABLE 4

FOLLOW-UP OF 52 CASES — OPEN PROCEDURES

7}

g

a

03

£

>

TL

73

a

C3

72

03

70

P4

a

<u

w

a

0

03

0 c

a

03

CD

O _H

^ C3
£ >
a 0

a

a

'4-1

70

'O

C &

0>

a

a 3

3

0

Method

0*

73

03

a

S-M

03

c3

03

O »-«
02 u

03

O

£

o*

C2

%£

1.

Iron Wire

22

14

18

5

36

14

41

18

2,

Silver Wire

6

17

17

17

67

3.

Crochet Cotton

8

13

13

73

4.

Patellectomy

16

6

62

30

6

30

All numbers (except

cases)

expressed

as

per

cent.

The cases fixed with iron alloy wire
showed the highest percentage of pain, in-
fection and subsequent removal. This sub-
stantiates again the work of Venable and
Stuck5 who emphasize the danger of using
metals with a marked tendency to undergo
electrolysis.

The cases fixed with silver wire showed
the highest percentage of breakage. This
could be anticipated in view of the low ten-
sile strength of silver wire.

The cases repaired with crochet cotton3
had the least amount of trouble. There were
no infections and no secondary operation
was necessary for removal of the cotton
loop.

The cases subjected to patellectomy
showed a high percentage of quadriceps
weakness and 30 per cent of these cases
had inability to extend the knee beyond 165
degrees extension.

REFERENCES

1. Bohler, L. : Treatment of Fractures, Baltimore, Wil-
liam Wood & Co., 1936. p. 374.

2. Davis, G. G. : Applied Anatomy, Philadelphia, J. B.
Lippincott Co., 1916. p. 539.

3. Loomis, L. K. : Internal fixation of fractures of the
patella with cotton suture material, Surgery, 15 :602, 1944.

4. Marsh, J. T., and Wood, F. C. : Introduction to the
Chemistry of Cellulose. D. Van Nostrand, New York, 1939.

5. Venable, C. S., and Stuck, W. G. : Electrolysis con-
trolling factor in the use of metals in treating fractures,
J.A.M.A., 111 : 1349, 1938.

THE VALUE OF CENTRAL FIELD
STUDIES OVER THE CONVENTIONAL

TYPE OF VISUAL FIELD STUDIES*

SHELLEY R. GAINES, M. D.f
New Orleans

Since a visual field examination is en-
tirely subjective, it is necessary to know
whether or not the information is accurate.
If the patient cannot be depended on for
his answers, the effort may be time wasted.
Before starting the screen examination, the
patient’s vision is tested; a careful exami-
nation with the ophthalmoscope is made
and a confrontation field is quickly taken.
Refractive errors are corrected if they are
of importance. In the absence of gross tem-
poral field defects, the blind spot is now
outlined on the screen with a suitable test
object usually 1 14 to 3 mm. while at 1,000
mm. distance. If this can be satisfactorily
done, the patient is cooperating. Some-
times when no gross hemianopia is present
and in the absence of fundus pathology, pa-
tients give inconsistent answers about the
blind spot — when this happens, the exam-
iner now quickly tests for the presence of
either a tubular or spiral field.

If such findings are demonstrated, the
chances are that a functional problem is
present. By these maneuvers on the tan-
gent screen in the beginning, the examiner
has tested the patient’s reliability as a sub-
ject. If he proves to be a poor one, the
examiner must use other methods than
fields, to study his case.

It is impossible to do good tangent screen
work without properly made test objects.
Those mounted on small black wires with
black cardboard handles sizes .6 mm., 1
mm., iy2 rnm., 3 mm. and 5 mm. as designed
by Dr. John M. Evans, have proved quite
satisfactory.

In perimetry work, ophthalmologists
probably take more visual fields on glau-
coma patients than patients with any other

*Read before the sixty-fifth annual meeting of
the Louisiana State Medical Society, New Orleans,
April 24-26, 1944.

fFrom the Department of Ophthalmology, Tu-
lane University School of Medicine.

Gaines — Central Field Studies

177

one condition. In glaucoma, field changes
show damage already done. It is therefore
essential to find the earliest changes and
watch their progress in order to treat the
disease properly. These early changes are
central. They are first seen with the 6 mm.
at 1,000; 1 mm. at 1,000, and I14 mm. at
1,000 isopters. When a big nasal step is
found in the 5 mm. isopter at 330 mm. dis-
tance, considerable damage has already oc-
curred.

The following cases illustrate some ad-
vantages of central fields.

CASE No. 1

A 55-year-old male was first seen in De-
cember of 1942, his right eye had been blind
for several years from glaucoma. The ten-
sion was 40 (Schiotz) the disk was cupped,
and atrophied. The left eye had a corrected

Date: l%/\/*+2-

V. O. S.:

Examiner:
V. O. D.:

vision of 20/15. The tension was 26
(Schiotz). The peripheral field was nor-
mal for 5/330 ; but the central field showed
a slight weakness in the temporal quadrant
of the two central isopters. After the pa-
tient was put on pilocarpine the tension in
his left eye came down to 18 (Schiotz) and
has remained at that level. The left field
has been checked every two or three months.
On February 14, 1944, he had a normal cen-
tral and peripheral field. Whether or not
the weakness of the central isopters as
shown on December 1, 1942, was due to
early glaucoma, I cannot say. It is suspi-
cious to say the least. This case is shown
to illustrate a possible early change in the
central field that is not shown at all on the
peripheral field.

Date: Examiner:

vos*>Ml* VOD,j//y/vy

Case 1-A

Case 1-B

178

Gaines — Central Field Studies

CASE No. 2

A 63-year-old woman whose vision in the
left eye, when seen April 28, 1943, was
20/40 plus. Her tension was 28 (Schiotz).
The peripheral field was normal. The cen-
tral field, however, showed a definite con-
striction of the 1/1000 and the .6/1000
isopters. Fields were taken at intervals
over a year’s time. The 5/330 isopter re-
mained the same. The two central isopters
gradually shrank until on March 24, 1944,
there was a nasal step in the .6/1000
isopter. The vision has remained the same.
The central field definitely shows, however,
that the glaucoma is not under control.

CASE No. 3

A 21-year-old man whose best corrected
vision in his right eye was 20/15. The
disk was cupped and his tension was 26
(Schiotz). The peripheral field showed a
slight nasal cut. The central field showed
definite glaucomatous changes a big Bjer-
rum scotomae above, a small one below, and
a marked constriction of the .6/1000 isopter.

CASE No. 4

A 55-year-old man whose vision was
20/20, in the right eye was seen because he
wanted his glasses changed. The tension
was .22 (Schiotz). The disk showed begin-
ning cupping. One half an hour after

Case 2-A

Case 2-B

Gaines — Central Field Studies

179

euphthalmine 5 per cent was instilled in the
right eye, the tension was 32 (Schiotz).
The peripheral field showed a suspicious
cut but the central field showed definite
glaucomatous changes.

CASE No. 5

This case of an elderly woman is shown
to demonstrate that although she has ap-
parently a nasal hemianopia in the left eye,
analysis of the central field shows a definite
glaucomatous type of change with a fairly
good central island of vision. Her vision
was 20/25.

SUMMARY

It is not possible in a limited time to cover
the entire field of perimetry in glaucoma,
but an attempt has been made to show the

necessity of central field studies to find and
follow early changes. To study perimetric
findings on any case, we must take into con-
sideration the central as well as the periph-
eral isopters, otherwise many early changes
will be overlooked.

DISCUSSION

Dr. Gilbert C. Anderson (New Orleans) : I

should like to ask Dr. Gaines the specific applica-
tion of this technic in surgical cases as they are
the ones in which I and some of my friends are
particularly interested. I have reference to bi-
temporal, homonymous and other field defects in
tumors or abscesses. In such surgical conditions is
there any advantage over the peripheral fields as
ordinarily taken?

Dr. Shelly R. Gaines (In closing) : I have never

Date:

Examiner:

Z. B.B.

Fundi:'

Remarks:

Case 3

180

Musser and Dempsey — Heart Disease

Date:

V.

Examiner:

V. O. D.:

Case 5

seen a case of heminopia demonstrated on the
tangent screen that did not show up on the peri-
pheral isopters.

0

THE INCIDENCE OF THE SEVERAL
ETIOLOGIC TYPES OF HEART
DISEASE IN THE CHARITY
HOSPITAL

J. H. MUSSER, M. D.t
and

C. S. DEMPSEYff
New Orleans

It may be of some interest to have a
knowledge of the incidence of hypertensive,
arteriosclerotic, syphilitic and rheumatic

fFrom the Department of Medicine, Tulane Uni-
versity School of Medicine, and the Charity Hos-
pital of Louisiana, New Orleans.

ffFrom the Record Room of Charity Hospital
of Louisiana, New Orleans.

heart disease in the Charity Hospital of
Louisiana at New Orleans. In order to
obtain these figures the number of patients
admitted with heart disease for the year
1942, the last year that complete summa-
ries may be obtained, will be given. The
age, sex and race of these persons may be
seen in chart 1. There were 2,059 patients
all told with the four most frequent types
of heart disease : parenthetically there were
36 others who had miscellaneous cardiac
diagnoses; congenital heart disease with
14 cases; functional heart disease with 13
instances, beriberi heart disease with five;
hyperthyroid heart disease with four, and
the heart of myxedema with one such diag-
nosis.

The number of patients who were diag-
nosed on leaving the hospital as having
hypertensive heart disease is more than
twice as many as of other three common
etiologic types of diseases of the heart.
There were 1,207 such patients discharged
in 1942.

The next in frequency to hypertensive
disease occurred arteriosclerotic disease
with 505 cases. Needless to state the
greater number of these patients were in
the old age group.

It is surprising there were only 174 cases
of syphilitic heart disease. Ninety-eight of
these individuals were in mid-age group
and only 76 had passed the age of 50.

The toll of rheumatic heart disease is
well exemplified in figures obtained from
the Record Room of Charity Hospital. In
the group of patients under 20 years of age
there were 67 patients discharged with a
diagnosis of rheumatic heart disease; in the
next three decades there were 88 and only
18 of the 173 patients lived to be over 50
years of age.

In the year 1942 there were 44,180 pa-
tients discharged from the hospital. The
break down of these figures is shown in
chart 2. It will be noted that all types of
heart disease were seen more frequently
proportionately in the colored than in the
white race. It may be noted as well that
hypertensive heart disease was in percent-

Mussek and Dempsey — Heart Disease

181

CHART 1

NUMBER OF CASES OF CARDIAC DISEASE OF VARIOUS ETIOLOGIC TYPES
ADMITTED TO NEW ORLEANS CHARITY HOSPITAL FOR THE YEAR 1942

2

yr. -

20 yr.

21

yr. -

50 yr.

51

yr. -

and up

Types

WM

WF

CM

CF

WM

WF

CM

CF

WM

WF

CM

CF

Total

Hypertensive

30

28

48

96

195

273

261

276

1207

Arteriosclerotic

9

6

1

6

168

132

135

48

505

Luetic

3

1

62

32

14

3

50

9

174

Rheumatic

14

12

24

17

16

20

8

44

7

6

2

3

173

age more frequent in the white female than
in the male of either sex, or in the colored
female. Syphilitic heart disease occurred
with a very much greater frequency in the
negro than in the white individual, figures
which are to be expected because of the

CHART 2

TOTAL ADMISSIONS — 1942

WM 8,434

WF 9,389

CM 10,593

CF 15,764

44,180

much greater incidence of syphilis in the
negro than in the white race.

It is rather surprising that there were
so many negro patients with rheumatic
heart disease, as this type of heart disease
is presumed to show a predilection for the
white race. These figures confound this
idea.

SUMMARY

A report is presented of the incidence of
types of heart disease that occur in the
Charity Hospital in a sample year. The
figures for the year 1942 are presented
and briefly discussed.

182

Editorials

NEW ORLEANS

Medical and Surgical Journal

Established 18JH

Published by the Louisiana State Medical Society
under the jurisdiction of the following named
Journal Committee:

Val H. Fuchs, M. D., Ex officio
For two years: G. C. Anderson, M. D., Chairman
Leon J. Menville, M. D.

For one year: J. K. Howies, M. D., Vice-Chairman
For three years: C. Grenes Cole, M. D., Secretary
E. L. Leckert, M. D.

EDITORIAL STAFF

John H. Musser, M. D Editor-in-Chief

Willard R. Wirth, M. D Editor

Daniel J. Murphy, M. D Associate Editor

COLLABORATORS— COUNCILORS
Edwin L. Zander, M. D.

J. T. O’Ferrall, M. D.

Guy R. Jones, M. D.

T. B. Tooke, Sr., M. D.

George Wright, M. D.

W. E. Barker, Jr., M. D.

C. A. Martin, M. D.

W. F. Couvillion, M. D.

Paul T. Talbot, M. D General Manager

1430 Tulane Avenue

SUBSCRIPTION TERMS: $3.00 per year in ad-
vance, postage paid, for the United States; $3.50
per year for all foreign countries belonging to the
Postal Union.

News material for publication should be received
not later than the eighteenth of the month preced-
ing publication. Orders for reprints must be sent
in duplicate when returning galley proof.

Manuscripts should be addressed to the Editor,
1130 Tulane Avenue, New Orleans, La.

The Journal does not hold itself responsible for
statements made by any contributor.

THE PHYSICIANS’ FORUM

The Bulletin of the Physicians’ Forum,
which is published by a small group of phy-
sicians who are advocating most vigorously
the passage of the Wagner-Murray-Dingell
Bill, contains on the last page a series of
excerpts from letters written by five doc-
tors scattered throughout the country, and
one from the Council of Social Agencies of
New Orleans. Most of the statements of
the physicians are quite non-commital but
the Journal would like to take violent excep-
tion to that one which has been signed

“Council of Social Agencies, New Orleans,
La.” The statement that is published is as
follows: “We are very grateful for the

brochure which you sent us. It looks excel-
lent and if it can be distributed widely it
should go far in counteracting the ob-
noxious material that has been circulated on
the other side.” The last sentence in this
statement is a very serious reflection on the
medical profession in the City and the State
which almost to a man is opposed to the
pernicious Wagner-Murray-Dingell Bill. It
is presumed that the material which is
spoken of as obnoxious has to do with that
which is being circulated by a very large
group of physicians in this country. We
would like to know why is this material ob-
noxious. Is it obnoxious to listen to or read
what the other side has to say on any con-
troversial subject? We would like very
much to know who has the authority to
write thus for the Council of Social Agen-
cies, which in many ways is closely tied up
with the medical profession. Has there
ever been any expression of opinion from
the Council as to whether this Council was
in favor of or against the socialization of
medicine? If an individual is responsible
for this statement signed by the Council of
Social Agencies, should not that individual
sign his or her name rather than attempting
to speak for the council as a whole?

The statement will leave a bad taste in
the mouth of the physician who is opposed
to the regimentation of medicine. This is
particularly so because the impression will
be left with the doctors throughout the coun-
try who read this avowal that it is made by
a Council representing a large group of New
Orleans citizens who, taking part in a de-
batable and controversial subject, is so nar-
row as to resent hearing what the other side
has to say. The quotation leaves very dis-
tinctly and definitely the impression that
representatives of New Orleans social agen-
cies and the citizens of the City are op-
posed to that which is most dear to the
heart of the physician, namely freedom to
maintain the high ideals of the medical pro-
fession without supervision from a host
of Washington bureaucrats.

Editorials

183

OTHER THINGS FIRST

A provocative editorial appeared in a re-
cent number of the New York State Journal
of Medicine from which it might be well to
quote one or two sentences and to paraphase
others. The editorial writer notes “that
medicine has progressed, developed, flour-
ished under nearly every kind of Govern-
ment which has had the common sense to let
it alone. It has developed great leaders,
good hospitals, it has conquered a great
many of the world’s greatest disease
scourges. As a nation we are living longer,
living healthier lives than almost any com-
parable group of people.” This is a definite
statement which cannot be disputed. What
medicine has accomplished has been done in
spite of the lagging behind of adequate
housing, proper sanitation, good nutrition,
favorable working conditions, all of which
when neglected tend to promote illness and
to impair the health of the poverty stricken.

The medical profession has kept the
people of the country well ; it is making
them live longer than ever before and for
practically every occasion where a doctor
has been needed one has been available.
Medicine has not promised innumerable
panaceas but it has educated and trained
good physicians and surgeons. That it has
been successful may be shown statistically
by the lowered death ra,te and incidence of
disease in this country in a period of war
and that in spite of fifty thousand members
of the profession being in the armed forces.
The health record of the Army and Navy,
for which the civilian physicians are in good
part responsible, has been remarkable.
Never has a war been fought with less sick-
ness and with less mortality from the
trauma of shot and shell ; 97 per cent of the
injured in battle recover, thanks to the effi-
ciency of the medical care given to the
wounded soldier, sailor and marine.

Before advocating regimentation of medi-
cine, should not the Government look pri-
marily on improving the living conditions
of the people as a' whole? Why should not
the Government have in the seats of the

mighty a representative of the medical pro-
fession? There should be a position in the
Cabinet for the head of a Department of
Health, a physician, who would have control
over the innumerable medical activities
which are carried on by nearly every de-
partment of the Government. Such a Cabi-
net member should be one qualified to
know about the problems of medicine in
their broadest aspects and his department
would be prepared to advise about, and to
direct, the health activities of this great
country.

o

THIOURACIL IN THE TREATMENT OF
THYROTOXICOSIS

Under the above caption, Williams and
Clute,* of Boston, report on the largest
series of patients treated with thiouracil
that has appeared in current medical litera-
ture. These two observers, working in the
Thorndike Memorial Laboratory and the
Massachusetts Memorial Hospitals, have
summarized the treatment of seventy-two
patients who had thyrotoxicosis. The pa-
tients included those who had Graves’ dis-
ease, toxic nodular goiter and toxic ade-
noma. The duration of illness extended
from as short a time as three weeks to
twenty-two years. Thirteen of these pa-
tients had previously had a subtotal thy-
roidectomy. All the patients were very
carefully studied and have been followed
for a sufficiently long time to warrant the
conclusions that Williams and Clute have
arrived at as a result of their observations
on this form of treatment — thiouracil.

In the original group of patients the
thiouracil was given in doses of one gram
a day, subsequently this dose was cut down
to 0. 6-0.4 gram and eventually to a dosage
of 0.2 gram daily after a period of six
weeks. Because of the possibility of a gran-
ulocytopenia being brought about by the
drug, blood counts were followed carefully,

* Williams, R. H., and Clute, H. M.: Thiouracil
in the treatment of thyrotoxicosis. New England
J. M., 230:657, 1944.

184

Editorials

as well as the basal metabolic rate. The
majority of the patients have been followed
for a period of from four to six months,
during which time practically all of these
patients maintained a normal basal meta-
bolic rate. The metabolic rate fell to nor-
mal in an average of within about five
weeks in the more severe cases, whereas in
the milder cases within a period of three
weeks. If the drug was discontinued it was
noted that the symptoms of thyrotoxicosis
returned in a relatively short time. This
does not imply, however, that the drug must
be continued indefinitely. In some cases
there can be no doubt but that there would
be a permanent disappearance of symptoms
after the patient has taken the drug for six
months or a year.. In other instances in-
dubitably the drug may have to be taken
for the lifetime of the patient, or until sub-
total thyroidectomy is performed.

In the seventy-two patients who were
studied by these two authors, one patient
developed agranulocytosis but recovered in
spite of continued therapy. Four patients
developed a morbilliform rash which dis-
appeared relatively promptly without dis-
continuation of the drug. Six of the pa-
tients developed edema of the legs, probably
due to retention of sodium chloride and wa-
ter as result of the treatment. Untoward
reactions occurred in only thirteen of the
seventy-two patients and in only three in-
stances was it necessary to discontinue
thiouracil.

Twenty-two of the patients were sub-
jected to thyroidectomy for reasons other
than an unsatisfactory response to the
drug. The glands that were removed at
operation showed a great variation, on
chemical analysis, in the amount of drug
present. There seemed to be no correlation
in the amount of drug in the gland and the
therapeutic response.

Thiouracil in the treatment of thyrotoxi-
cosis opens up a new field of chemothera-
peusis. The experiences of Williams and
Clute and many other observers indicate
that the basal metabolic rate can be brought
to a normal level, can be maintained there

and when held at this level there occurs
clinical remission of the thyroid disease.
The tachycardia, the nervousness, the diar-
rhea, the weight loss and other symptoms
disappear. The ocular symptoms do not al-
ways disappear as happily as do the nervous
and cardiac symptoms.

The use of thiouracil is fairly widespread
throughout the country. There exists a dif-
ference of opinion among various observers
who have employed thyrourea in hyperthy-
roidism. Some hold that the drug should be
used only in the preoperative treatment of
thyroid disease and that as soon as the pa-
tient is in good physical condition, the thy-
roid gland should be removed. Others be-
lieve that thiouracil may do away with op-
eration on the thyroid gland completely.
Probably a middle of the road position
would be the best one to take; in patients
with severe or relatively severe thyrotoxi-
cosis, thyroidectomy should be done inas-
much as these people will never be free
from symptoms unless the drug is continued
all their life. In mild cases certainly it
would seem to be well worth while to keep
the patients on thiouracil for a considerable
length of time with the hopes that ultimate-
ly the drug may be discontinued and the
patient may make a complete recovery
without having to undergo the vicissitudes
of an operation.

o

PHONES FOR THE SICK
President Val H. Fuchs has obtained
a full statement from the Southern Bell
Telephone Company relative to new phones
for those people who are sick. This state-
ment appears in the Louisiana section
of the Journal. The form that is supplied
to the applicant who wishes to install a tele-
phone must be answered by the physician
without any qualifications. Question num-
ber two for example must be categorically
answered with a “yes.” The president of
the State Society also wishes it to be noted
that there is a $10,000 penalty if the ques-
tions are answered improperly.

Organization Section

185

ORGANIZATION SECTION

The Executive Committee dedicates this page to the members of the Louisiana
State Medical Society, feeling that a proper discussion of salient issues will contri-
bute to the understanding and fortification of our Society.

An informed profession should be a wise one.

RESPONSES OF SUCCESSFUL CANDI-
DATES IN THE RECENT PRIMARY
TO PROPOSED LEGISLATION
BEFORE THE CONGRESS

The following men were written to for
their reactions in regard to various matters
which involve medical legislation:

Candidates for United States Senator:
Charles C. Gerth, New Orleans; Griffin T.
Hawkins, Lake Charles; John H. Overton,
Alexandria; E. A. Stephens, New Orleans.

Candidates for United States Congress-
men: First District — Milton J. Burg, St.
Bernard; J. Aubrey Gaiennie, New Orleans;
F. Edward Hebert, New Orleans; Milton J.
Montifue, New Orleans. Second District —
William Dane, New Orleans; Allen H. John-
ess, Westwego; Paul H. Maloney, New Or-
leans; Alexander E. Rainold, New Orleans;
James M. Thomson, New Orleans; Henry
Vosbein, New Orleans. Third District —
Robert F. DeRouen, New Iberia; James
Domengeaux, Lafayette; Louis J. Michot,
Lafayette; Robert L. Mouton, Lafayette;
Albert 0. Rappelet, Houma. Fourth Dis-
trict— Overton Brooks, Shreveport; George
T. Shaw, Shreveport. Fifth District —
Charles E. McKenzie, Monroe. Sixth Dis-
trict— Franz J. Baddock, Baton Rouge; H.
Alva Brumfield, Baton Rouge; George M.
Lester, Bains; James H. Morrison, Ham-
mond; Murphy J. Sylvest, Hammond; Wil-
ford L. Thompson, Baton Rouge. Seventh
District — Henry D. Larcade, Jr., Opelou-
sas; Paul C. Reed, Ville Platte. Eighth Dis-
trict— A. Leonard Allen, Winnfield.

Responses were received from the follow-
ing stating that they were opposed to the
Wagner-Murray-Dingell Bill and for the
most part were opposed to failure to defer
medical students. On the other hand they
were in favor of House Bill No. 4663, which
has to do with all medical matters being
handled by a health department :

Messrs. Charles C. Gerth, New Orleans;

Griffin T. Hawkins, Lake Charles ; John H.
Overton, Alexandria; E. A. Stephens, New
Orleans; Milton J. Burg, St. Bernard; F.
Edward Hebert, New Orleans; William
Dane, New Orleans; Paul H. Maloney, New
Orleans; Henry Vosbein, New Orleans;
James Domengeaux, Lafayette; Louis J. Mi-
chot, Lafayette; George T. Shaw, Shreve-
port; George M. Lester, Bains; James H.
Morrison, Hammond; Henry D. Larcade,
Jr., Opelousas; A. Leonard Allen, Winn-
field.

The letters of those Congressmen who
won in the recent primary and who an-
swered our letter are printed in full togeth-
er with the letter of Congressman J. H.
Morrison who is in the run off - in the
Sixth District:

UNITED STATES SENATE
Washington, D. C.

John H. Overton, Louisiana

Alexandria, Louisiana
August 21, 1944

Dr. Edwin L. Zander

Chairman, Committee on Maternal Welfare

La. State Medical Society

1430 Tulane Avenue

New Orleans, 13, Louisiana

Dear Dr. Zander:

Your letter of the 17th instant addressed to Sen-
ator Overton is acknowledged in his absence. As
you probably know, Senator Overton received a call
and felt it was his primary duty to return to
Washington to be on hand at the time important
postwar legislation was being framed.

The Senator has gone on record and has stated
from time to time that he is opposed to socialized
medicine and to the enactment of S. 1161, known
as the Wagner-Murray-Dingell Bill.

For your further information I enclose herewith
copy of radio speech delivered by the Senator on
August 1 in which on pages 10 and 11 you will
find his statement with regard to socialized med-
icine.

With respect to the other Bills mentioned in
your letter, H.R. 5027, H.R. 5128 and H.R. 4663,
as I recall these Bills have not been reported by
the House of Representatives and therefore have
not as yet come to the Senate for action.

I am sending your letter to Senator Overton in
Washington for I am sure he will want to know

186

Organization Sectioyi

of the views of the Louisiana State Medical Soci-
ety on these important measures.

Very truly yours,

(Signed) RUTH D. OVERTON,

Secretary.

CONGRESS OF THE UNITED STATES
House of Representatives
Washington, D. C.

F. Edward Hebert,

1st District Louisiana

Committees :

Naval Affairs
District of Columbia

August 26, 1944
Dr. Edwin L. Zander, Chairman
Committee on Maternal Welfare
Louisiana State Medical Society
1430 Tulane Avenue
New Orleans, 13, Louisiana

Dear Dr. Zander:

Replying to your circular letter of August 17th,
I answer your questions as follows:

(1) I am opposed to the Wagner-Murray-Dingell
Bill, socialized medicine.

(2) I am in favor of deferring medical students.

(3) I am in favor of all medical matters being
handled by the Health Department, therefore, fa-
vor H.R. 4663.

Sincerely yours,

(Signed) F. EDW. HEBERT

CONGRESS OF THE UNITED STATES
House of Representatives
Washington, D. C.

Paul H. Maloney
2d District Louisiana

Member of the Committee
on Ways and Means

August 26, 1944

Dr. Edwin L. Zander, Chairman,

Committee on Maternal Welfare,

Louisiana State Medical Society,

1430 Tulane Avenue,

New Orleans, Louisiana.

Dear Dr. Zander:

Your letter relating to legislation that has been
introduced in Congress, and asking my views in
reference thereto, has been received.

In reply, I wish to say that the so-called Wag-
ner-Murray-Dingell Bill is one that has many pro-
visions— some of them I favor, while others I
do not. In reference to the particular provision
that you asked about, I am not in favor of this
provision.

In regard to H.R. 5128, which supercedes H.R.
5027,1 wish to say that this bill has been referred
to the Military Affairs Committee with no action
being scheduled, and pertains to the deferment of
medical and dental students. It is quite likely
that circumstances that are in the offing will pre-
clude the need of this legislation.

As to H.R. 4643, this bill has been referred to
the House Committee on Expenditures in the Exe-
cutive Department and it also' has not been
scheduled for consideration — -the provisions are to
transfer certain health functions to the Depart-
ment of Public Health. Such legislation would
appear logical, however, I would like to have fur-
ther information on the proposal.

Appreciating your views at all times, and al-
ways welcoming your suggestions, I am with best
wishes

Sincerely yours,

(Signed) PAUL H. MALONEY

CONGRESS OF THE UNITED STATES

House of Depresentatives
Washington, D. C.

James Domengeaux
3d Cong. Dist. Louisiana
Committees :

Elections No. 1, Chairman
Insular Affairs
Irrigation and Reclamation
Merchant Marine and Fisheries
Mines and Mining
World War Veterans’

Legislation

Lafayette, La.,
September 14, 1944
Dr. Edwin L. Zander, Chairman
Committee on Maternal Welfare
La. State Medical Society
1430 Tulane Avenue
New Orleans 13, Louisiana

My dear Dr. Zander:

Your letter of August 17 was received, and I
would have answered sooner but I have been so
very busy in connection with my campaign for
re-election to Congress.

I am not a Member of Congress at this time and
will probably not be eligible to resume my seat
until after the November election. However, I
will be glad to keep in mind the legislation you
referred to and give it every consideration if it is
still pending action when I return to Congress.

With all good wishes, I am

Sincerely yours,

(Signed) JAMES DOMENGEAUX

CONGRESS OF THE UNITED STATES
House of Representatives
Washington, D. C.

James H. Morrison
6th District Louisiana

August 23, 1944

Dr. Edwin L. Zander
1430 Tulane Avenue
New Orleans 13, La.

Dear Dr. Zander:

I have your letter of August 17th asking me to
state my position on several pieces of proposed

Orleans Parish Medical Society

187

legislation. In this connection will state that I
am unalterably opposed to legislation that will
socialize the practice of medicine.

Regarding the deferment of medical students
will state that I realize the medical profession is
being called upon to contribute heavily to the war
effort and undoubtedly is suffering proportion-
ately in our war casualties with other professions.
You may be sure that I favor adequate steps to
assure having the needed number of physicians for
the postwar period.

It is difficult to give a 100% commitment for
or against a certain piece of legislation until it
actually reaches the floor of the House for con-
sideration, as very often amendments are adopted
that entirely change the application of the act for
what it was intended by its sponsor.

I am sure that I am in accord with principles
with which the medical profession is working and
which it seeks by the two pieces of legislation
above referred to.

I am indeed glad to have your views regarding
H.R. 4663 and assure you that this legislation will
have my careful consideration when it reaches
the floor of the House for consideration.

Sincerely yours,

(Signed) JAMES H. MORRISON M.C.

CONGRESS OF THE UNITED STATES
House of Representatives
Washington, D. C.

Henry D. Larcade, Jr.

7th District Louisiana
Committees :

Rivers and Harbors

Flood Control

Territories

Education

Pensions

Patents

August 21, 1944

Dr. Edwin L. Zander, Chairman
Committee on Maternal Welfare
Louisiana State Medical Society
1430 Tulane Avenue
New Orleans 13, Louisiana

Dear Dr. Zander:

Y«ur letter to Congressman Larcade, dated
August 17, has been received. The Congressman

was called to Washington to vote on important leg-
islation; however, it is expected that he will re-
turn here within a few days. At that time your
letter will be called to his attention.

I can assure you that Congressman Larcade is
always glad to have your views on matters of
public interest, and he wants you to continue to
feel free to advise him at any time.

Yours truly,

(Signed) RUBY DUGGAN,

Secretary to Congressman Larcade

CONGRESS OF THE UNITED STATES
House of Representatives
Washington, D C.

A. Leonard Allen
Sth Dist. Louisiana

Committees :

Census, Chairman
Flood Control

Immigration and Naturalization
Elections No. 2

World War Veterans’ Legislation
Pensions

August 25, 1944

Dr. Edwin L. Zander
1430 Tulane Avenue
New Orleans, Louisiana

Dear Dr. Zander:

I have your letter with reference to the Wag-
ner-Murray-Dingell Bills, and also with reference
to the Miller bills. On the question of socialized
medicine, I have repeatedly stated my position ver-
bally and in writing to numerous physicians in
the 8th Congressional District. I have respect for
the medical profession, and I want it to remain
unbossed.

I have not had an opportunity to analyze the
Miller bills, but I shall be happy to give those my
most earnest consideration when and if they come
before the House for action. The medical profes-
sion in the 8th Congressional District knows that
on medical questions I have great respect for the
opinion expressed by the profession.

Sincerely yours,

(Signed) H. LEONARD ALLEN,

Member of Congress

■O

TRANSACTIONS OF ORLEANS PARISH MEDICAL SOCIETY

CALENDAR OF MEETINGS

October 2. Board of Directors, Orleans Parish
Medical Society, 8 p. m.

October 3. Eye, Ear, Nose and Throat Staff,
8 p. m.

October 4. Mercy Hospital Staff, 8 p. m.

October 5.

October 9.
October 11.

Clinico-pathologic Conference, Touro
Infirmary, 11:15 a. m.

Executive Committee, Baptist Hospi-
tal, 8 p. m.

Scientific Meeting, Orleans Parish
Medical Society, 8 p. m.
Clinico-pathologic Conference, Chari-

188

Louisiana State Medical Society News

October 16.
October 17.

October 18.

October 19.

October 20.
October 24.
October 25.

October 26.

October 27.
October 30.

ty Hospital Morgue Amphitheater,
1:30 p. m.

Clinico-pathologic Conference, Marine
Hospital, 7:30 p. m.

Touro Infirmary Staff, 8 p. m.

Women’s Auxiliary, Orleans Parish
Medical Society, Orleans Club, 3
p. m.

Hotel Dieu Staff, 8 p. m.

Charity Hospital Medical Staff, 8
p. m.

Charity Hospital Surgical Staff, 8
p. m.

Clinico-pathologic Conference, Touro
Infirmary, 11:15 a. m.

I. C. R. R. Staff, 12:30 p. m.

Baptist Hospital Staff, 8 p. m.

Clinico-pathologic Conference, Charity
Hospital Morgue Amphitheater,
1:30 p. m.

Clinico-pathologic Conference, Marine
Hospital, 7:30 p. m.

French Hospital Staff, 8 p. m.

Catholic Physicians’ Guild, 8 p. m.

Clinico-pathologic Conference, Touro
Infirmary, 11:15 a. m.

DePaul Sanitarium Staff, 8 p. m.

New Orleans Hospital Dispensary for
Women and Children Staff, 8 p. m.

Board of Directors, Orleans Parish
Medical Society, 8 p. m.

NEWS ITEMS

Dr. B. Bernard Weinstein was recently elected
to membership in the American Association for
the Study of Sterility.

Dr. George E. Burch attended a meeting in
Washington, called by the Office of the Air Sur-

O-

geon, to discuss medical problems of altitude fly-
ing.

Dr. Sam Nelken has been appointed visiting lec-
turer in social psychiatry at Louisiana State Uni-
versity, these duties being in addition to his duties
as clinical instructor on the faculty of the School
of Medicine of the University.

Dr. Nathan Polmer attended the annual nation-
al convention of the American Congress of Physi-
cal Medicine in Cleveland.

Dr. Ralph V. Platou has been promoted from as-
sociate professor to professor of pediatrics in the
Tulane University School of Medicine.

Lt. Col. Michael E. DeBakey, who has recently
been advanced to that rank, read the citation from
the War Department and presented E pins “for
meritorious and distinguished service to the United
States of America” when the New Chileans Red
Cross Blood Donor Center was awarded the Army-
Navy “E” for its “outstanding record in having
procured approximately 75,000 pints of blood for
the armed forces.” Lt. Col. DeBakey is now at-
tached to the Office of the Surgeon General in
Washington.

Dr. Edwin L. Zander has been elected to the
Board of Directors of the Louisiana League for the
Hard of Hearing.

The Society had the misfortune of losing two
of its active members, Dr. Hermann B. Gessner
and Dr. R. S. Crichlow.

Daniel J. Murphy, M. D.,

Secretary.

LOUISIANA STATE MEDICAL SOCIETY NEWS

CALENDAR

Society

East Baton Rouge

Morehouse

Orleans

Ouachita

Rapides

Sabine

Second District

Shreveport

Vernon

PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS

Date

Second Wednesday of every month
Second Tuesday of every month
Second Monday of every month
First Thursday of every month
First Monday of every month
First Wednesday of every month
Third Thursday of every month
First Tuesday of every month
First Thursday of every month

Place

Baton Rouge
Bastrop
New Orleans
Monroe
Alexandria

Shreveport

INFORMATION FOR PHYSICIANS AND SUR-
GEONS IN LOUISIANA REGARDING TELE-
PHONE SERVICE FOR PATIENTS
In order that you may be better informed with
reference to certain requirements of the War Pro-

duction Board’s Order placing restrictions on tele-
phone service and the provisions made therein in
the case of serious illness and certain other disabil-
ities, we are quoting below excerpts from the
WPB’s instructions to physicians and surgeons as

Louisiana State Medical Society News

189

shown on the certification Form WPB1-2101. Cer-
tain parts of the Form itself are reproduced with
suggestions that may prove helpful.

EXCERPTS FROM W. iP. B. s INSTRUCTIONS

This order gives preference in obtaining service
in two types of cases where it is properly certified
that unreasonable hardship exists. Where tele-
phone service is furnished as a result of such cer-
tification it means delaying the furnishing of serv-
ice to a residential applicant whose application has
been pending longer. The two types of cases are:

CASE 1

Residence service where the attending physician
or surgeon certifies on the Schedule B Certifica-
tion Form that there exists a condition of serious
illness or pregnancy involving serious complica-
tions, that he must be called repeatedly at un-
predictable intervals for emergency treatment and
that in view of all the circumstances telephone
service is essential. Such service shall be termi-
nated within 30 days of the termination of the
conditions specified above.

CASE 2

Residence service required where a person lives
alone and the attending physician certifies on the
Schedule B Certification Form that such person
is confined to residence quarters for a protracted
period by reason of serious illness or physical
disability and that in view of all the circumstances
telephone service is essential. The phrase “lives
alone” includes a person who is alone all day or
during the day or night working hours, except for
one or more children aged 10 years or younger
or another person similarly certified to be confined
to residence quarters by reason of serious illness
or physical disability. Such service shall be termi-
nated within 30 days after the termination of the
conditions specified above.

Information to be Supplied by Physicians or
Surgeons on the Certificate Form

1. General nature of present illness or physical
disability: State diagnosis in non-technical langu-
age, as far as possible. In pi’egnancy cases de-
scribe complications.

2. If Case 1, state whether the serious illness
or pregnancy condition requires that the attend-
ing physician or surgeon be called repeatedly at
unpredictable intervals for emergency treatment.
If Case 2, state whether the serious illness or
physical disability described above requires con-
finement of the patient to residence quarters for
a protracted period.

3. State whether in view of all the circum-
stances telephone service is essential: Answer each
question 2 and 3 “yes” or “no” based on the need
for residence telephorie service arising from the
condition described in question 1 above.

4. Probable date of termination of physical con-
dition set forth above: The answer to this ques-
tion should be definite enough to enable the Tele-
phone Company to know when the telephone would
be subject to disconnection.

If you have had an occasion to execute this cer-
tificate for a patient you have no doubt observed
reference there on to the United States criminal
code which emphasizes the need for carefulness in
the preparation of certificates so as to avoid any
statement that might be interpreted as an inten-
tional violation.

AMERICAN COLLEGE OF SURGEONS CAN-
CELS 1944 CLINICAL CONGRESS
The American College of Surgeons, upon action
of its Board of Regents, has cancelled its Annual
Clinical Congress because of the acute war situa-
tion that has developed, involving greater demands
than at any time in the past upon our transporta-
tion systems for the carrying of wounded military
personnel, troops, and war materiel. The Con-
gress was to have been held in Chicago, October
24 to 27.

Dr. Irvin Abell of Louisville, Chairman of the
Board of Regents, in making the announcement,
said that this action was taken after consultation
with officials in Washington.

SALATICH HONORED
Captain M. A. Salatich, the son of Dr. P. B.
Salatich, has been awarded the Bronze Star for
“meritorious service in action from D-Day to the
capture of Cherbourg.” Captain Salatich has been
in the service for a year after graduating from
Louisiana State University Medical School and
completing his internship.

NEWS ITEM

Dr. Vincent J. Derbes has recently been hon-
ored by election to membership in the American
Academy of Allergy.

THE AMERICAN FEDERATION FOR
CLINICAL RESEARCH
The regular meeting of the American Federa-
tion for Clinical Research was held on August 23,
1944, in the Hutchinson Memorial Building at 8:30
p. m. The program consisted of the following:
Discussion of the Acute Diarrheal Diseases by Dr.
James Watt; Electroencephalography by Dr. Walk-
er Thompson; The Effect of Ouabain on the Elec-
tracardiogram by Drs. Richard Ashman, Leonard
Apper and Edgar Hull; The Role of the Liver in
the Metabolism of Paraldehyde by Philip Hitch-
cock.

ARMY DEATH RATE AT ALL-TIME LOW
The disease death rate among American soldiers
of World War II is the lowest ever recorded for

190

Louisiana State Medical Society Neivs

the U. S. Army and only one-twentieth as high
as that of World War I thanks to an effective
program of military preventive medicine, Brig.
Gen. James S. Simmons, chief, Preventive Medicine
Service, U. S. Army, reported.

NEWS RELEASES FROM THE OFFICE OF
THE SURGEON GENERAL
In the recent news releases there were two items
of information concerning members of the State
Medical Society :

Major M. E. DeBakey of the General Surgery
Branch of the Surgery Division, Office of The
Surgeon General, has recently been promoted to
the rank of Lieut. Colonel. He has been on duty
in the Office of The Surgeon General since Janu-
ary 29, 1943.

Lieutenant Colonel Roy H. Turner, M. C., Chief
of the Communicable Disease Treatment Branch of
the Medical Consultants Division, Office of The
Surgeon General, has been on a tour of temporary
duty in the field (Sept. 12 to Sept. 20). Colonel
Turner visited the Vascular Center at DeWitt Gen-
eral Hospital, Auburn, Calif., and the Rheumatic
Fever Centers at Torney General Hospital, Palm
Springs, Calif., Bruns General Hospital, Santa Fe,
N. M., and Foster General Hospital, Jackson, Miss.
During the course of this trip, Colonel Turner
represented the Surgeon General at the Regional
Meeting of the American College of Physicians at
Vancouver, British Columbia. He delivered two
addresses; one on The Control of Streptococcus In-
fections with Sulfonamides and the other on The
Hepatitis Problem in the Army.

An item of interest has to do with the reorgani-
zation of the office of the Surgeon General. This
news release is as follows:

The post of Assistant Surgeon General, to be
filled by Brigadier General Raymond W. Bliss,
was created in a partial reorganization of the Sur-
geon General’s Office it was announced on August
25. General Bliss will hold the new post in addi-
tion to his duties as Chief, Operations Service.

The Assistant Surgeon General will act for the
Surgeon General in coordinating the work of the
Operations Service, the various professional divi-
sions, the Military Personnel Division and the ac-
tivities of other divisions and services that affect
operations.

Other organizational changes include dissolving
of the Administrative Service, the Fiscal, Legal
and Office Service Divisions of that service will
report directly to the Executive Officer as previ-
ously; the Professional Service is dissolved and
four Professional Consultant Divisions are created
as follows: Medical, Surgical, Neuropsychiatric
and Reconditioning; the Nursing Division is dis-
solved and all personnel and related aspects of the
Army Nurse Corps will be the responsibility of

the Army Nurse Branch of the Military Person-
nel Divisions, Personnel Service with over-all
policy aspects of the Army Nurse Corps the re-
sponsibility of the newly constituted Nursing Di-
vision of the Professional Administrative Service.

POLIOMYELITIS

The peak of the 1944 epidemic of infantile
paralysis for the nation as a whole apparently has
been passed, and the incidence of the disease is
now tapering off. The heaviest incidence of cases
for the nation occurred in the week of September
2 when 1,683 cases were reported to the U. S.
Public Health Service. The week of September 9
showed a drop to 1,487, and reports since then
from epidemic states indicate the decline is con-
tinuing.

The total for the year up to September 9 was
10,959 cases, or more cases for the comparable pe-
riod than at any time since America’s worst epi-
demic year in 1916.

This year’s total for the first 36 weeks is 2,030
cases higher than for the same period in 1931,
which to date is the second highest epidemic year.

POSTGRADUATE COURSES OF THE AMERI-
CAN COLLEGE OF PHYSICIANS
The American College of Physicians has ar-
ranged a series of postgraduate courses in various
medical centers throughout the United States. The
first of these courses is in cardiology and will be
held October 2-7 at the Massachusetts General
Hospital, Boston. Course II in general medicine
will be conducted by the staff of the University of
Oregon, Portland, October 9-14. In this same week
the University of Minnesota Medical School, Min-
neapolis, will hold a course in internal medicine,
during which time those who register for the
course will be housed on the campus and will have
their meals served in the dining room of the Cen-
ter for Continuation Study Building. The week
of October 16-21 there will be held a course in
allergy at the Roosevelt Hospital, New York City,
under the direction of Dr. Robert A. Cooke. Course
V will be devoted to internal medicine and will last
for two weeks. Various Chicago institutions are
taking part in this course which will include many
phases of medicine. The last course that has been
announced is one that will be held in the special-
ties of medicine, including heart disease, arthritis,
metabolic diseases, chemotherapy, gastroenterology,
allergy and infectious diseases. This course is also
for two weeks and will commence December 4.
The participants in this course will be members
of the faculty of the several medical schools in
Philadelphia. The bulletin announcing these post-
graduate courses and giving the details of the pro-
grams that have been arranged may be obtained
from Mr. E. R. Loveland, executive secretary of
the American College of Physicians, 4200 Pine St.,
Philadelphia 4, Pennsylvania. Attendance of

Louisiana State Medical Society News

191

course is not limited to members of the College.
No registration fee will be charged any medical
officer of the armed forces of this country or of
Canada.

INFECTIOUS DISEASES IN LOUISIANA
The Louisiana State Board of Health reported
fhat during the week ending August 12 malaria
led all other reportable diseases with 103 cases
listed. Fifty-five of these cases were reported
from East Carroll Parish and 30 from Jackson.
The diseases occurring in numbers greater than
10 included 36 cases of bacillary dysentery, 25
of pulmonary tuberculosis, 16 of unclassified pneu-
monia, 11 of poliomyelitis, and 10 of mumps. For
the week which closed August 19 there were listed
28 cases of pulmonary tuberculosis, 24 of malaria,
16 of unclassified pneumonia, 15 of typhus fever,
and 11 of mumps. Four cases of poliomyelitis
were reported this week. Typhus fever was re-
ported from eight parishes scattered over the state.
For the week which closed August 26 there were
reported 42 cases of pulmonary tuberculosis, 20 of
malaria, 13 of typhus fever, and 11 each of mumps
and whooping cough. Only two cases of poliomye-
litis were listed this particular week. The week
ending September 2 was the particular week in
which venereal diseases are reported for the preced-
ing month. There were listed 1,558 cases of gonor-
rhea, 1,109 of syphilis, 29 of chancroid, and 16 of
lymphopathia venereum. Of the other diseases
there were 107 cases of unclassified pneumonia, 52
of pulmonary tuberculosis, and 26 of pneumococcic
pneumonia. Of the venereal cases 639 gonorrhea
patients, 81 of the syphilis patients, and 3 of the
lymphopathia venereum were reported from mili-
tary sources. Tuberculosis led all the reportable
diseases for the week of September 9, at which
time 32 cases were reported to the State Board
of Health. In order of frequency this was followed
by 30 cases of malaria, 14 each of typhoid fever
and of unclassified pneumonia, and 12 of typhus
fever, of which six were reported from Orleans
Parish. The typhoid fever cases were scattered
pretty widely throughout the state. There were
four cases of poliomyelitis reported for this par-
ticular week.

HEALTH OF NEW ORLEANS
The Bureau of the Census, Department of Com-
merce, reported that for the week ending August
12 there were listed 126 deaths in the City of New
Orleans divided 77 white, 49 colored, with 20 of
the deaths occurring in children under one year
of age, 16 white, 4 colored. For the week ending
August 19 there were roughly the same number
of deaths as the previous week. Eighty-six of
these were in the white race, 45 in the colored,
with 11 infant deaths. One hundred and thirty-
nine deaths were recorded for the week ending
August 26. Eighty-nine of these deaths were in

the white population and 50 in the colored, with
only 10 infant deaths. For the week which termi-
nated September 2 the 145 deaths that took place
in the City of New Orleans were divided 89 white,
56 colored, and 18 in infants, seven of whom were
white and 11 were colored. For the week of Sep-
tember 9 there was a sharp decrease of the deaths
in the city only 114 people expiring of whom 71
were white, 43 were colored, and 21 were infants,
separated 11 white and 10 colored.

THEY DIED FOR THEIR COUNTRY

The following graduates of Tulane University
School of Medicine have given their lives while in
the service of their country. Their year of gradu-
ation, location and what they were doing prior to
going into service have been stated after each
name.

Josiah Dozier Bancroft, ’31, was a surgeon in
Birmingham, Alabama.

Raynor Elmore Holmes, Jr., ’33, was located in
Canon City, Colorado.

William A. Hutchinson, ’24, was in general prac-
tice in Texarkana, Arkansas.

William I. Hunt, ’42, of Greenville, Mississippi,
was an intern at the Charity Hospital in New*
Orleans.

John Mitchell Johnson, Jr., ’36, was in practice
in Longview, Texas.

Felix Benjamin Long, Jr., ’40, was in Washing-
ton, D. C.

Walter O. McCammon, ’35, was serving a resi-
dency in Boston.

Gus W. Thomasson, Jr., ’36, was located in Dal-
las, Texas, where he specialized in obstetrics and
gynecology.

Harry Eugene Teasley, ’28, was a surgeon prac-
ticing in Robinson, Illinois.

William Lee Tucker, ’28, engaged in practice in
Cullman, Alabama.

Z. B. Weingart, Jr., ’42, was an intern at Chari-
ty Hospital.

DR. HERMANN B. GESSNER
(1872- 1944)

Another past president of the Louisiana State
Medical Society passed away on August 31.

Dr. Gessner was at one time, until his retire-
ment on account of ill health, one of the outstand-
ing surgeons of the City of New Orleans. He was
for many years surgeon at the Charity Hospital
and was professor of clinical surgery at Tulane
School of Medicine. Likewise for many years he
was a frequent contributor to medical literature,
his publications being numerous and valuable.

Dr. Gessner was president of the Orleans Par-
ish Medical Society in 1902 and the Louisiana State
Medical Society in 1930-31. He held many posi-
tions of responsibility and trust in the State Medi-
cal Society, among which he was a member of the

192

Book Reviervs

Journal Committee. He was also a Fellow of the
American College of Surgeons, a member of the
Southern Surgical Association, the Southern Medi-
cal Association and of course the American Medi-
cal Association.

With the death of Dr. Gessner Louisiana loses
one of its outstanding medical men who contributed
much to the advancement of organized medicine.
Dr. Gessner had a host of good friends; nobody
could have been an enemy to this lovable, con-
scientious, and splendid surgeon.

DR. RICHARD S. CRICHLOW
(1882 - 1944)

A well known eye, ear, nose and throat spe-
cialist died September 6 in New Orleans. Dr.
Crichlow resided in New Orleans since 1918. He
was active in church and medical circles in the

city. For twelve years he was in charge of the
out-patient dispensary of the Veterans’ Bureau.
He was a lieutenant colonel in the Medical Re-
serve (inactive) and was on the staff of the Touro
Infirmary.

DR. JOSEPH LEVY
(1880 - 1944)

Dr. Joseph Levy was born in 1880, and gradu-
ated from the School of Medicine of Tulane Uni-
versity in 1902. He died in New Orleans on July
8, 1944.

DR. WILLIAM HENRY PIPES
(1878 - 1944)

Dr. Pipes of Jackson, Louisiana, died on July 8,
1944. He was born in 1878 and graduated from
the School of Medicine of Tulane University in
1906.

0

BOOK REVIEWS

The Management of Neurosyphilis : By Bernhard

Dattner, M. D., Jur. D., New York, Grune &

Stratton, 1944. Pp. 398. Price, $5.50.

Unique in its scope, this book presents the fruits
of a distinguished career in investigating and treat-
ing neurosyphilis.

Since neurosyphilis is eminently a chronic dis-
ease, whose effects sometimes become apparent
only in old age, it is important to ascertain whether
the inflammatory process is still going on, smolder,
ing beneath the surface or already arrested. It is
obviously not true as some physicians still believe
that this question can be solved by a routine phy-
sical examination.

After a systematic review of all methods of treat-
ing neurosyphilis the author states that, regarding
fever therapy, the newer methods are certainly not
overwhelmingly superior to their predecessors and
cannot be considered as true substitutes for ma-
laria treatment. He also says that no proper
syphilis therapy can be undertaken without cogni-
zance of spinal fluid findings.

For the further development of syphilis therapy
Doctor Dattner urges the close cooperation of the
general practitioner, the dermatologist, the intern-
ist, and the neurologist. The latter’s great inter-
est in such cooperation stems from the fact that
he usually appears on the scene when the nervous
system has already suffered irreparable damage
and he is then confronted with an insoluble prob-
lem.

The entire subject of neurosyphilis is adequately
and thoroughly covered in this splendid work which
has been presented in a concise, interesting and
comprehensive way. An excellent bibliography is
included.

C. P. May, M. D.

Vines Diseases in Man , Animal and Plant: By

Gustav Seifert. Transl. by Marion Lee Taylor,

New York Philosophical Library. 1944. Pp.

332. Price, $5.00.

The publisher’s notice and the author’s preface
both point out that the voluminous literature about
viruses and virus diseases has increased rapidly,
especially within the past decade. Dr. Seiffert
states, “In the present work an attempt is made
to give a survey of the momentary status of virus
investigation with special consider ation of the most
recent literature, especially foreign” (italics those
of the reviewer). This would be a most laudable
project, since in the past five years our knowledge
of many of the virus diseases has increased tre-
mendously and in numerous instances fundamental
data which were previously lacking have been sup-
plied. There already exists several excellent sur-
veys of various aspects of the virus diseases which
review the literature comprehensively up to 1938,
such as those of Doerr and Hallauer, in German
(1938); Levaditi and Lepine, in French (1938);
van Rooyen and Rhodes, in English (1940) ; Har-
vard School of Public Health Symposium on Virus
and Rickettsial Diseases (1940). In addition to
the foregoing, which are concerned primarily with
human infections, there is a recent English sum-
mary (1943) of virus diseases in plants, by Baw-
den. The value of Dr. Seiffert’s book would there-
fore rest primarily on the summarization of the
pertinent literature up to 1943 or at least 1942.
Actually there is not a single reference in the
entire book to experimental work published after
1937. Since none of the references are to papers
which appeared less than seven years ago and most
of the references are considerably older, the book

Book Revieivs

193

"has failed in its chief purpose, namely to bring
the reader up to date in the knowledge of viruses.

In addition to the foregoing the book has many
other serious faults, some of which may be men-
tioned.

1. The author defines viruses as agents “which
apparently can only maintain themselves in close
symbiosis with living cells” (p. 2), yet he discusses
under the heading of “Virus-Like Organisms” the
Bartonella and the agents of the pleuropneumonia
group, which have been cultivated on artificial
media in the absence of living cells. He also dis-
cusses, under the heading of “Certain and Ques-
tionable Virus Diseases of Man,” scarlet fever and
whooping cough which are now generally accepted
as being bacterial in origin.

2. There are several contradictions of statement
in the author’s treatment of various virus diseases;
e. g., in speaking of herpes simplex he states, “It
is not quite certain that guinea pigs are subject
to this infection” (p. 113). Yet later on the same
page the inoculation of the plantar surface of the
guinea pig foot is noted as a useful method of ob-
taining experimental infection. On p. 74 he states
regarding the precipitation reaction in variola and
vaccine, “Nothing more detailed is known about
the nature of this reaction,” yet proceeds in the
following paragraphs to present data which throw
much light upon the factors involved. Stanley’s
tobacco mosaic virus is referred to as exhibiting
the properties of both albumin and of globulin, on
one page (35) .

3. There are important lapses due to the pro-
longed lag between the material covered and pres-
ent-day knowledge, e. g., his statement (p. 79),
indicating that effective immunization against vi-
rus diseases is only attainable with living virus.
In the case of equine encephalomyelitis, it has been
conclusively demonstrated for several years now
that inactivated virus preparations will induce ef-
fective immunity if the quantity of antigen is suf-
ficiently great. Again, in the case of St. Louis
encephalitis it is stated, “An assumed transmission
of mosquitoes could not be considered” (p. 226),
whereas in actuality the mosquito has been clearly
implicated as a vector.

4. From the bibliographical standpoint this book
leaves much to be desired, a) There are frequent
misspellings of the names of investigators to whose
work reference is made (over 25 such errors were
noted), b) The references have not been carefully
checked. For example the only reference to a
paper published after 1937 is an article by Wooley
and Armstrong which is said (p. 227) to be in
Public Health Reports for 1943. On checking, it
appears that the paper actually appeared in 1934.
A paper by Sabin is erroneously given (p. 102)
as published in 1915 instead of 1935; a paper by
Ledingham and McClean is given (p. 99) as ap-
pearing in volume 36 of the British Journal of
Experimental Pathology, whereas this volume is

not expected to appear in print for several years
yet. The work of Aujesky on pseudo-rabies is
given (p. 222) as dating from 1932 although the
journal reference is dated 1902. c) The abbrevi-
ations for names of journals are sometimes han-
dled in a careless fashion. The Journal of Pathol-
ogy and Bacteriology is referred to as J. of Path,
(p. 69 or as J. of Exper. Bact. (p. 97) ; the Brit-
ish Journal of Experimental Pathology is given as
J. exper. Path. (p. 71) ; Public Health Reports is
given as Publ. Health (p. 83) ; Canadian Journal
of Public Health is given as Cand. Publ. Health J.
(p. 146) or as Canad. Publ. Health (p. 103) ; Jour-
nal of Experimental Medicine is given as J. of
exper. (p. 154). d) In the references, the volume
number of the journal is sometimes omitted; some-
times no year of publication is given.

5. There is abundant evidence that the translator
is unfamiliar with scientific English as well as the
current terminology in the field of virus investiga-
tion. Saline solutions are referred to as “cooking
salt” solutions (pp. 51 and 144) ; dextrose as “grape
sugar” ; billion is “milliard” (p. 142) ; virus propa-
gation and respiration are given as “breeding”
and “breathing” respectively (pp. 4 and 9) ;
minced tissue becomes “pap of tissue” (p. 12) ;
agent (of disease) is translated as “stimulus” (p.
1) ; virus sediment becomes “dregs” (p. 16) ; anti-
serum is “antitoxin” (p. 16) ; nasal washings be-
come “lotions of the nose” (p. 154); egg mem-
brane is “egg skin” (p. 20) ; experimental animals
are “experiment animals” (p. 152) ; whole blood
becomes “full blood” (p. 65) ; bite of flies is “sting
of flies” (p. 64) ; size of a (microscopically) resolv-
able particle is “size of a soluble particle” (p. 25) ;
rabbits injected with is “rabbits sprayed with” (p.
36). Agglutinated is given as “agglutinized” (p.
73) ; Brownian movement is “Brown’s molecular
movement” (p. 16) ; bile is “gall” (p. 108) ; cell
inclusions are “cell inclosures” (p. 114) ; non-
motile rickettsiae are “immovable” p. 278) ; strains
of virus are “stocks” (p. 147) ; healthy individ-
uals are “sound” (p. 245) ; latent virus is trans-
lated as “slumbering” virus (p. 16) ; intracerebrally
injected virus is “incorporated” virus (p. 61); fil-
tered is “filtrated” (p. 281) ; trench fever is “rifle
pit fever” (p. 279) ; paralysis is “lameness” (p.
203).

6. Many words are misspelled, e.g., antigenic
(antigene p. 2) ; asterococcus (asterococcous p.
273) ; bronchitis (bronchites p. 1943) ; diphtheria
(dipteria p. 109) ; ectromelia (ectromelie p. 134) ;
endocrine (endoctrine p. 204) ; ganglion (gaglion
p. 60) ; haematoxylin (haematoxilin p. 304) ; in-
oculate (innoculate p. 75) ; kaolin (caolin p. 31) ;
lymphogranuloma inguinale (lymph granuloma in-
guinal p. 15) ; lapine (lapina p. 91) ; leptospira
(leptospires p. 9) ; lysogenic (lysogen p. 297) ;
murine (muriner p. 279) ; neurotropic (neurotrop
p. 165, neurotrop p. 237) ; Pediculus (pediculous p.
130) ; pneumosintes (pneomosintes p. 144) ; prop-

194

Book Reviews

erties (proprieties p. 37) ; ricinoleate (ricineolate
p. 209) ; themselves (themelves p. 5; trocar (troi-
car p. 168) ; varioloid (variloid p. 119) ; viscero-
tome (viscerotrom p. 168).

7. It is surprising to find statements such as the
following: “Viruses are not harmed by repeated
freezing' and thawing up to 185°C” (p. 49). “Ph.
7.4 is the most favorable number” (p. 97). “With
this centrifuge from 55 up to 6000 revolutions are
possible” (p. 41).

8. Aside from the above inaccuracies there are
many evidences of ineptness in translation, e.g.,
“Granuloma of the lymphatic glands breeds deadly
encephalitis in mice to a high degree after a few
transmissions.” (p. 52). “Lipsehutz. has priority
in the matter of a name, who termed the group
stronglyloplasma.” (p. 17). “Cases of generalized
vaccine after inoculation were indicated variously
as a fermentation of vaccine in variola.” (p. 98).
“The antigene structure is as good as not worked
on at all.” (p. 74). “But the sickness of their in-
oculation leads to secretion of virus, it can easily
be protracted in uninoculated stocks.” (p. 110).
“For the correctness of this view speak the experi-
ments of Galloway, etc.” (p. 75). “With very
slight addition of formalin, virus is heated so long
until it is apathogene.” (p. 127). “In the Porto
Rico stock which is infectious for mice in a dilution
of 1:1 million, it might concern a virus very malig-
nant for mice.” (p. 147). “For this reason the
protection inoculation of a fellow fever very ef-
fective in itself with neurostrop virus alone, is not
to be recommended for general intromission, pre-
ferably on the other hand one with tissue cultures
from chicken embryos with brains removed.” (p.
78). “For concentrating the virus by means of.
filtration membrane filters are used in the first
rank.” (p. 40). “Their content of fatty substances
is remarkable, which can be stained with osmic
acid — ”. (p. 109). “They obtained fever and ex-
anthem with wash water of the throat from earlier
stages of the disease, filtered and unfiltered, in
monkeys, even if irregular, and further transfer-
ence in transmissions also succeeded.” p. 136).

9. The following is a partial list of the investi-
gators whose names have been misspelled, with the
ei'rors and the pages on which they occur noted in
parentheses: Barnard (Bernard p. 305) ; Bengt-
son (Bengston p. 232) ; Blanc (Blane p. 173) ;
Borna (Barna p. 22); Conor (Connor p. 282);
Corey (Corey p. 36) ; Findlay (Findley p. 110) ;
Hass (Han p. 22); Hornus (Hormus p. 203);
Hoyle (Woyle p. 151); Kligler (Kliger p. 7); Ko-
dama (Kodannas p. 21) ; Kuttner (Huttner p.
197) ; Laidlaw (Laidlow p. 161) ; Merrill (Merril
p. 237) ; Mueller (Miller p. 94) ; Olitsky (Olitzky
p. 238) ; Perdrau (Perdreau p. 59, Perdrean p.
227) ; Petrie (Petze p. 34) ; Pirquet (Pirquets p.
165) ; Saddington (Seddington, Seddingtom p.
112); Sauton (Sayton p. 295); Schwentker
(Schwendtker p. 158) ; Siler (Siller p. 172) ; Stokes

(Stoke p. 27) ; Trager (Trages p. 260) ; Tulloch
(Pulloch p. 74).

In summary, then, it may be said that this vol-
ume suffers grievously from numerous errors of
omission and commission. It would seem to this
reviewer that the reputations of author, translator
and publisher would be served best by withdrawing
this book from the market until it has been sub-
jected to a complete revision.

Morris F. Shaffer, D. Phil.

Psychology of Women: By Helene Deutsch, M. D.

New York, Grune & Stratton, 1944. Pp. 399.

Price $4.50.

This book is a psychoanalytic interpretation of
the normal psychic life of women and their normal
conflicts. It is the first of two volumes and deals
with the individual development and personality of
woman. The second volume will deal with her role
as a servant of the species.

The author brings out in her observations that
the understanding of individual psychology and
normal biology of woman is essential to the cor-
rect understanding of situational and cultural fac-
tors in a woman’s life. Furthermore it appears
that social changes for the emancipation of women
and other moves to improve environment fail if
they deprive women of their natural role and re-
sponsibilities and feminine satisfactions. “In the
Middle Ages, when women were most subjected so-
cially, chivalrous love and the knight’s humble
service of his lady were most widespread.”

Passivity as well as suffering for the sake of
love are normal feminine characteristics too often
belittled, renounced and struggled against with dis-
astrous results. The various attributes of the nor-
mal feminine erotic women are discussed in com-
plex detail. The book develops the growth of these
characteristics step by step from the girl-child to
the adult woman.

One of the best contributions of this book is the
presentation of the relationship of the girl to her
mother. This relationship is particularly critical
in the prepuberty period of between 10 and 12
years. The normal drive to grow up and achieve
something is strong at this time when the girl is
preparing herself to meet adults with as much
knowledge and training as possible before she must
take on the special role of womanhood. At this
period sexuality has less reality than at any other
time. The ego development is at its height. The
young girl, striving for independence, becomes ex-
tremely critical of her parents and particularly of
her mother. She tries to copy screen stars and
heroines of books instead of patterning after her
mother. For the mother now represents infantile
dependency which the girl is trying to renounce.
She imitates other adults. The girl’s play acting
may cause her to be continually meddling in the af-
fairs of grown people often making a nuisance of
herself and acting like a hypomaniac. She keeps

Book Reviews

195

her secrets from her mother and confides only with
girls her own age. If the mother cannot respect
the girl’s independence, thei’e will be difficulties.
The attempt to tear herself away from her mother’s
influence frequently brings on an intensified
anxious urge to remain under the maternal protec-
tion with a “passive clinging and a querulous de-
mand for love that is difficult to satisfy”. “In the
prepuberty of girls attachment to the mother rep-
resents a greater danger than attachment to the
father’ — the condition of ‘psychic infantilism’ found
in many adult women represents the outcome of an
unresolved attachment to the mother during pre-
puberty.” If the girl’s conflict is not made worse
by the motherliness of the mother she will return
during puberty and throughout adult life to a har-
monious relationship with the mother, who remains
an ideal and friend in times of stress. The author-
quotes from D. H. Laurence: “My son is my son

till he takes him a wife. My daughter’s my daugh-
ter the rest of her life.”

Walker Thompson, M. D.

Female Endocrinology : By Jacob Hoffman, A. B.,

M. D. Philadelphia, W. B. Saunders Co. 1944.

Pp, 788. Price, $10.00.

This book is well written and easy to read. It
has many illustrations, which are capably selected
and highly instructive. This is one of the best and
most useful text books on endocrinology and should
be a must on the list of every gynecologist and
those interested in endocrine therapy and disorders.

The author has clearly and concisely covered
the field of the clinical aspects of reproductive and
gonadal endocrinology, and has also included a dis-
cussion of glandular physiology in general. The
clinical material is conservatively and critically
handled. Animal experimentation is included, but
is clearly defined as being experimentation, and
the large jump between animal experimentation
and clinical application is clearly indicated. The
section on laboratory tests and diagnostic age is
of considerable value, and it is indeed useful to
have them available in a well organized and pre-
sented form.

There is an exhaustive and critical review of!
the literature on endocrinology, and an extensive
bibliography is added to each chapter. In addi-
tion there is an extremely valuable concluding
bibliographic index.

This book is recommended without reservation
to those interested in the field of gynecologic
endocrinology and endocrinology in general.

B. B. Weinstein, M. D.

Jews in Medicine : By Harry Friedenwald, M. D.
Baltimore, Johns Hopkins Press. 1944. 2 Vols.
Price, $3.75 each.

This two volume work, the “Jews in Medicine”
contains a number oif well written and carefully
planned essays by a student and a scholar, who is

at the same time a very fine physician. This rep-
resents a labor of love. As Dr. Sigerist points
out in the preface, Dr. Harry Friedenwald is an
unusual personage in medicine. He is one of those
ardent book collectors, who in Baltimore, centered
around William Osier, Howard Kelly, William Hal-
stead and Henry Barton Jacobs. Friedenwald not
only collected books pertaining to the history of
Jews in medicine, but read and studied them. As
a result of his years of arduous study he has been
able to present a considerable amount of new ma-
terial, well organized and carefully thought over,
covering many of the fields of endeavor of the
Jews in medicine, which were previously relatively
unknown.

These two volumes contain a large number of
essays of Dr. Friedenwald, which were previously
published elsewhere, and several new ones which
are published here for the first time. The entire
book makes informative and pleasurable reading,
and throws a highlight on an aspect of a History
of Medicine, which has previously been not too
well illumined. Volume I contains an introductory
essay about Jewish Book Lovers, which is quite
interesting. It then contains a group of essays on
the practice of Medicine among the Jews. A group
of essays on ancient and medieval Jewish Physi-
cians, and a group on Jews in the early Universi-
ties, and concludes with a group of biographical
sketches, including those of Jacob Vahalon, Fran-
cisco Lopez D. de Villalobos, The Doctors da Veiga,
Abraham Zacutus, Ludovicus, Mercatus, Lusitanus,
and concludes with an essay on some Jewish in-
terests of a Marrano Physician.

Volume II includes a large number of extremely
interesting essays, including one on two Jewish
physicians of the 16th Century; a description of
a 16th Century Consultation of Doctors, Medical
pioneers in the East Indies, some notes on the
history of Jewish Hospitals, an interesting essay
concerning diseases of the Jews, and some ophthal-
mological notes of Jewish interest. There is then
an interesting group of chronicles of Jewish physi-
cians in Italy, and in Spain and Portugal, and
South Eastern France. There is an excellent
group of references including many, which are
found solely in the author’s library, and a very
well worked out index.

It is not often that I have an opportunity to
review a book of the general excellence of this
work of Friedenwald. It is recommended unhesi-
tatingly to those who have an interest in the his-
tory of medicine.

B. Bernard Weinstein, M. D.

Industrial Ophthalmology : By Hedwig S. Kuhn, M.
D. St. Louis, C. V. Mosby Co. 1944. Pp. 294.
Price, $6.50.

This interesting volume of three hundred pages
is reasonably well organized and written. In the
first section, the visual aspects of job analysis are

196

Book Reviews

explained and numerous visual tests and technics
are detailed. Then follows an explanation of ex-
isting relationships of visual acuity, stereopsis,
muscle balance and color perception to numerous
jobs in many industries. A very well written sec-
tion on industrial eye injuries by Dr. Albert Snell
is then presented. The last chapters are devoted
to eye protection and recent ophthalmic problems
in industry. The illustrations which number about
one hundred and twenty-five are excellent, includ-
ing photographs, sketches and graphs which add
greatly to the text. Especially in the postwar pe-
riod and in less highly industrialized sections, this
volume will serve a very useful purpose. In Louisi-
ana, for example, relatively few plants conduct
visual surveys such as those suggested by the au-
thor, largely because of the cost involved and the
fact that the importance of industrial ophthal-
mology is not yet understood.

Chas. A. Bahn, M. D.

Diseases of the Eye: By Charles H. May, M. D.

18th Ed. Baltimore, Wm. Wood & Co., 1943.

Ulus. pi. fig. Price, $4.00.

The present edition which appeared shortly be-
fore the author’s death is a fitting tribute to his
memory. This little classic has passed through 62
editions in 11 languages and during its 42 years of
existence has served more physicians than any book
ever written on ophthalmology. Several factors
have contributed to its great success. It appeared

at the end of the quiz-compend era, presents only
the clinically important and useful, the material is
arranged in an exceptionally orderly manner and
is presented in an unusually simple, clear style,,
and frequent revisions have kept it up to date.

In the present edition, the chapters on Lacrimal
Diseases and Errors of Refraction have been re-
written, and those on Compensation Standards and
Military Requirements have been revised.

Several discrepancies in regard to current
ophthalmological thoughts exist. Future authors
should consider the advisability of enlarging the
table of contents to facilitate the finding of de-
sired information and modernizing several illustra-
tions such as those of test frames and case.

Chas. A. Bahn, M. D.

PUBLICATIONS RECEIVED

Lea & Febiger, Philadelphia: Diseases of the Di-
gestive System, edited by Sidney A. Portis, B. S.,
M. D., F. A. C. P.

The Williams & Wilkins Company, Baltimore:
Malaria: Its Diagnosis, Treatment and Prophy-
laxis, by William N. Bispham, Colonel, U. S. Army,
M. C., retired. Plaster of Paris Technic, by Edwin
O. Geckeler, M. D.

W. B. Saunders Company, Philadelphia and Lon-
don : Operations of General Surgery, by Thomas
G. Orr, M. D. Manual of Military Neuropsychiatry,
by Harry C. Solomon, M. D. and Paul I. Yakovlev,
M. D.

New Orleans Medical

and

Surgical Journal

Vol 97 NOVEMBER, 1944 No. 5

MANAGEMENT OF CERTAIN TYPES

OF FRACTURES INVOLVING THE
SHAFT OF LONG BONES*

F. WALTER CARRUTHERS, M. D.f
Little Rock, Ark.

Ifc is with a feeling of profound pride that
I have been extended the honor and privi-
lege to address this assembly representing
the medical profession of the state of
Louisiana — the elite — I should say — and
honored Indeed to be your guest speaker on
this occasion.

It will be the purpose of this presentation
to bring to your attention for your consider-
ation, our experience with the treatment of
certain types of fractures of the shaft of
long bones and what has been our treat-
ment, and to offer to you the manner in
which we have dealt with the (different
problems these types of fractures present.
This presentation is based on a review of
our records of some 85 cases of fractures
involving the shafts of long bones of the
human body.

The majority of the cases involved the
middle and lower thirds of the tibia as seen
in what Is commonly called the “Bumper
Fracture”, and fractures at different levels
of the shaft of the femora.

In all of the cases not one failed to unite
finally.. The amount of time required for
union to occur varied with the different
bones involved and the type of fracture
being treated.

In appraising a fracture from any stand-

*Read before the sixty-fifth annual meeting of
the Louisiana State yiedical Society, New Orleans,
April 24-26, 1944.

fFrom the Department of Orthopedic Surgery
of the University of Arkansas Medical School.

point, one must see more than the fracture
itself. Our ultimate goal must be a return
of function to meet all the requirements
necessary for the injured part to perform
its former duties. The time element re-
quired in a certain number of weeks should
and must be forgotten, for too often the sur-
geon as well as the patient thinks only in
terms of six, eight or ten weeks.

Most surgeons have patience to wait only
from one operation to the other and not for
the patient to have time to get well. They
lack, as the late John Ridlong once said
“orthopedic instinct”, for they expect all
simple fractures to become united in from
four to six weeks, after that it is an un-
united fracture.

The sooner we learn to forget the num-
ber of weeks it may require a fracture to
heal and quit thinking in terms of specified
time, the sooner all of us will become better
orthopedic surgeons.

Remember what Tally rand once said “Be
zealous; but don’t be too damned zealous.”
Too, what Alonzo Clark said “Don’t treat
your patient too much, let them get well if
they can.”

A trained surgeon with the right concep-
tion and ideas of the fracture problem
should be able to reduce most fractures of
the long bones by proper manipulation and
traction accompanied with adequate immo-
bilization, and thus be able to direct all sub-
sequent treatment of the patient to a com-
plete and successful recovery.

This idea would result in the successful
treatment of many fractures of the long
bones that would not become necessary to

198

Carruthers — Fractures of Long Boyies

open operations under less skillful surgeons’
care.

Even under ideal conditions, however,
there are many types of fractures of long
bones that can and should be treated more
successfully by certain internal fixations of
the fragments, and the surgeon in charge
should be prepared to follow that technic.

In making this statement, I am not un-
mindful of the recent article by Edwin W.
Ryerson, of Chicago, published in Indus-
trial Medicine on “Conservative Treatment
of Fractures of the Long Bones.” He said
“Conditions are now different from the
days of thirty odd years ago, for the types
of fractures produced and often seen today.
A modern surgeon on having a fracture of
the humerus, or fracture of the femur to
come on his services will say to himself.
Had I better wire this or had I better put
it up with a Lane plate, Sherman plate or
vitalli um plate, or had I better transfix the
fracture with long screws or nails.” He
then continues his dissertation with a con-
servative plea for treatment.

All of which is definitely true. However,
I am of the opinion that certain types of
fractures of the long bones can be more
successfully treated by methods which I
hope to impress you with in this paper.

In following out the methods advocated
here, one naturally must be possessed with
a knowledge of bone surgery, and in a po-
sition to apply the additional equipment
necessary to carry out these principles
along with the proper background of good
mechanical sense of the principles of proper
splinting and the proper training necessary
to apply them.

In bringing to your attention the use of
a removable screw, or the use of a Lane or
Sherman plate for the treatment of certain
fractures of the long bones, it must be un-
derstood from the start that these methods
are not a panacea for all fractures even of
the type and types here to be shown and
discussed, as there are different plans and
methods used or can be used for a success-
ful reduction of the fracture in question.
There are likewise different methods of in-

ternal fixation with just as equally good
results.

We all know that internal fixation is an
old principle practised by Allen, Thompson,
Sanderson, Sherman and others, dating
back 25 years or more, with good results in
selected cases. One of the purposes of this
paper is to suggest and bring to your at-
tention the present usefulness of a remov-
able screw used and advocated by Carrell,
Driver and Stuck, Carrell being the in-
ventor of the type of screw and Stuck the
type of metal used. All of us appreciate
the great contribution made in bone surgery
by Stuck and Venable on the use of vital-
liuiri metal; this was undoubtedly a God
send to the surgical world.

In advocating the use of the removable
screw in the treatment of certain types of
fractures of the long bones, particularly the
oblique fracture in the lower or middle third
of the tibia, or the same type in the radius
and ulna, and certain long or short oblique
fractures in the lower one-third of the hu-
merus as well as the femur, does not. by any
means meet every demand for ideal fixa-
tion. On the other hand, neither do other
fixation devices in general use meet every
desired requirement. Here, as elsewhere,
our own ingenuity and mechanical sense
must play a part in judging if one is to use
this or that method.

Fractures are too individual, and the sur-
geon in charge must have at his command,
surgical, mechanical and other common
sense ability, in order to combat the many
difficult, unseen, and unexpected problems,
that may arise with each case.

Our beloved Winston Churchill, in one of
his many expressions, told us to expect
great sacrifice of blood, sweat and tears
before this present war could be won;
how true is this in our everyday practice of
surgery. Maybe we do not sacrifice un-
necessary blood, but I am sure you will
agree with me that before we accomplish
the desired results in many of our fracture
cases, much sweat and often tears are sacri-
ficed. The restoration of these fractures
are many times a Herculean task. If one
does not have at his command all that may

Carruthers— Fractures of Long Bones

199

be desired, obviously the next best method
would naturally have to be resorted to. It
is not enough to save the lives of these pa-
tients— our ultimate goal must be a return
of function as near normal as humanly pos-
sible.

In our experience of some 85 cases, in-
cluding several varieties of fractures, we
have found that fixations of the nature
herein to be described have proved to be
adequate, provided the screw or pin is pro-
perly inserted and in most cases held with
external fixation of plaster.

External fixation of plaster and the
screw properly inserted, adequately con-
trols completely the tendency for angula-
tion, in the great majority of cases, until
complete or satisfactory union has occurred.
The method and procedure are relatively
simple and easily carried out, so that a
rather major operation under skilled hands
ca2i be within the sphere of a greater num-
ber of surgeons, provided he has mechanical
knowledge enough to warrant his attempt-
ing such a procedure.

With the background of good mechanical
sense, a familiarity of the proper principles
of splinting and good surgical training in
bone surgery, one may and should consider
open operation with more or less impunity.

This is further evidenced by our present
day knowledge of asepsis, surgical technic
and operative preparations, and with the
type of the metal now inserted and applied
to bones in general, has reduced the former
hazards in bone surgery to a minimum.
However, I am not unmindful of the fact
that the general surgeon, not accustomed to
doing bone surgery, should be warned of at-
tempting in general the assuring principles
that it is always a safe and sane procedure
to operate upon fractures without a thor-
ough knowledge of the procedure to be un-
dertaken. However, I am sure that a skill-
ful technic will permit a trained operator
to apply the methods herein described,
being always mindful of the fact that each
and every case is a law unto itself.

The principles of sound fixation in frac-
ture treatment are obtained in most cases
by suitable traction and fixation. Not in-

frequently, however, some types of internal
fixation may be required, though the ap-
plication of it should not be classified or
recommended as a panacea for fracture
treatment, but merely as a mechanical pro-
cedure in carrying out a principle of good
fixation.

Fractures not properly reduced and cer-
tain types of comminuted and oblique frac-
tures of the long bones can be treated far
better and the fragments held in a secured
and fixed position by the use of certain in-
ternal fixation, combined with adequate ex-
ternal fixation of plaster. It is unnecessary
to discard other accepted methods of in-
ternal fixation, but rather we should
choose a method to be used that suits the
type of fracture with which we are dealing.
There are no definite rules. In other words,
one should use the method with which he is
familiar, and the technic which produces the
best results in his hands.

Never treat an open reduction of any
kind as simple operation. There is none in
my experience which requires better judg-
ment and more perfect technic. Do not be
too prone to criticize unless you have tested
the method in question. Mature judgment
and the results of long experience are neces-
sary to determine without trial which frac-
ture will have to be opened for proper fix-
ation and which may or can be reduced and
maintained without open operation.

Non-union occurs in some cases regard-
less of what is done, yet in the majority of
cases it is due to improper fixation. Fixa-
tion is paramount, and must be absolute and
maintained over a sufficient period of time
for union to occur. Herein, does the in-
ternal fixation play its most needed role,
for it helps to maintain the parts in a fixed
position long enough for healing to com-
plete itself.

A discourse on the treatment of fractures
of the long bones would be incomplete, in
my opinion, if I did not call to your atten-
tion, even though this principle has been
repeated again and again, namely “the basis
upon which all successful treatment of frac-
tures has been founded is traction, applied
in some manner.” If one chooses the closed

200

Carruthers — Fractures of Love/ Bones

method for treating a fracture of the shaft
of the femora in a child, Russel’s traction
method by all means should, in my opinion,
be the treatment of election, except in those
cases involving the extreme upper third of
the femoral shaft, then of course the so-
called overhead traction, in which the limb
is attached by Buck’s extension to the over-
head bar with sufficient weight to overcome
shortening and angulation, is used. The
Russell extension was devised and published
first in 1923 by R. Hamilton Russell of Mel-
bourne, Australia, however, it did not at-
tract much real attention in this country
before 1927, and even today does not, in my
humble opinion, receive the general use it
should. Every general practitioner or sur-
geon treating fractures should have among
his armamentarium, a Russell traction out-
fit and should be well acquainted with its
method of application. It is very simple and
yet so effective; especially is it worth its
weight in gold, when one is called upon to
treat a fracture of the mid-shaft of the fe-
mora and he cannot have at his command
any more worth-while appliance than his
own ability to properly apply Russell’s trac-
tion. In children its usefulness is unpai’al-
leled and can be used in the adult case as
well.

The Thomas splint — the Boheler Braunts
splint, also is a worthwhile method, es-
pecially the later in the treatment of adult
fractures of the shaft of the femora. The
principle reason I dislike either of the two
later methods, it requires constant and pro-
longed hospitalization and meticulous care
and daily supervision, while on the other
hand after proper internal fixation the pa-
tient can at least, in the majority of cases,
spend a greater part of his convalescence
at home. Fractures of the shaft of the hu-
merus, not including fractures of the sur-
gical neck, or supracondylar have been
shown, in a large per cent of cases, can be
treated very satisfactorily by closed reduc-
tion using the hanging cast method, advo-
cated by Caldwell of Cincinnati. It goes
without saying that in certain complicated
and unusual cases this will not apply.

For the introduction and fixation of the
removable screw, an open exposure is made
of the fracture site of sufficient length to
give adequate exposure to the fracture, the
fragments are approximated, the bones are
held with a bone clamp after which the re-
movable screw’, or if a plate is your choice,
is applied. Be sure that the screw used,
w’hether of the removable type, or the Lane
plate type, is of sufficient length to pass
through the cortex from side to side, in
other wmrds, so that the end of the screw
can be seen protruding through the cortex
on the opposite side. This is very import-
ant for secured fixation.

Where the removable screwr is inserted
in certain selected cases, a separate punc-
ture w7ound is made at a selected site for
the screw’ to be passed through the fracture
site obliquely. This is also important, be-
cause we do not want the extended portion
of the screw which remains outside to come
through the original exposure wound.

It may, of course, be necessary to insert
twro screws, depending on the fracture, but
in the mapority of cases one is sufficient.
In cases of comminuted fractures the main
fragments are drilled and the smaller pieces
are then placed in as near anatomic reposi-
tion as possible. A snugly fitted circular
cast is then applied to include the movable
joints above and below the fracture.

No set time for the removal of the screw
has been followed. Frequent roentgeno-
grams are made to determine progress of
the callus formation and when in our judg-
ment, sufficient amount has occurred, the
cast and screw are removed, followed with
another cast, which is to remain until heal-
ing is complete. (Editorial note: Dr. Car-
ruthers then showed a large number of
slides illustrating from the onset of the
fracture to its perfect reduction. Space
does not permit the publication of these
roentgenograms.)

These and many others too numerous to
illustrate show the wide usefulness with
which this type of fixation may be em-
ployed. This plan of fixation as stated in
the beginning is not a proposal to meet all
requirements, but certainly does meet a

Orr — Compound Fractures

201

need in certain selected cases which we have
found very adequate and more or less
easily applied and worthy of recommenda-
tion.

It is my further opinion that the sugges-
tions here made will be found to be sound,
logical and meet all the basic mechanical re-
quirements needed to restore fractures of
this nature anatomically. If we remember
further that fractures of the long bones
must be treated by those same principles
which govern the treatment of fractures
elsewhere; and too, if we remember that
these injuries, serious as they sometimes
are, may and can be greatly relieved or even
completely restored by the application of
sound mechanical reasoning well applied, a
great deal, if not all of the apprehension
felt by the surgeon, as well as the patient,
can be entirely relieved.

Let me conclude this dissertation by
thanking you for your kind attention and
with the hope that we have at least given
you something to think about.

. BIBLIOGRAPHY

Can-ell, W. B. : End results in 100 fractures treated by
internal removable fixation, J. Bone & Joint Surg., IS :
408, 1936.

Arnold, I. A. : Different methods of internal fixation in
fractures, South. M. .T., 25 :971, 1932.

Carrel), W. B. : O'pen operation in the treatment of frac-
tures, Texas State J. M„ 27 :238, 1931 & 1932.

Crowell, B. C. : Report of symposium on metallic fixation
in fractures, Surg., Gynec. & Obst., 68 :57G, 1939.

Gilcreest, Edgar L. : Fractures of long boner, Am. J.
Surg., 28 :754, 1935.

Conn. H. R. : Internal fixation of fractures, J. Bone A
Joint Surg.. 13:261, 1931.

Carrell, W. B. : Treatment of fractures in the lower-
third of the log, South. M. .T., 26 :1054, 1933.

Carrell, W. B. : Removable internal fixation in fractures,
•T. A. M. A., 96 :671, 1931.

Magunson, Paul B. : Fractures, 1933, Philalelphia, J. B.
I.ippincott Company.

DISCUSSION

Dr. H. Theodore Simon: (New Orleans) : I can
always recall Dr. Carruthers holding for us a most
excellent four-ring circus in Little Rock, Arkan-
sas, when he entertained the Clinical Orthopedic-
Society of America. I was impressed with his
volume of cases and his excellent presentation and
the fact that he, alone, entertained us for one
whole day and we were thoroughly entertained and
given much excellent information. I am sorry that
we did not have a larger crowd to hear Dr. Car-
ruthers.

As those of you who have seen my moving pic-
tures over a period of years know, I have preached
conservation where it can be done, especially by

men not trained so thoroughly in surgery of bone
and joint structures. Unfortunately the general
surgeon does not realize that the same technics
used at other operations do not suffice for bone
surgery. We can not breathe in the joint, bone
or wound, while the gynecologist can expectorate
in an abdomen and get away with it. Unfortu-
nately there has been a wave of operative surgery
in fractures in the war and I am sure the men
coming back will feel that that is the correct thing,
especially near the front lines and in front hos-
pitals. They have not followed final results in
these cases. We are too prone to call a success
where it is not a success in patients who require
months and years of treatment.

I heartily agree with Dr. Carruthers in common
sense application in the treatment of fractures.. I
believe those of us who handle these can treat
conservatively and are better off than when using
gadgets.

Dr. Carruthers spoke of long enough fixation
and proper fixation. If improper and too short
there will be bad union.

As a specialist in this section I am frequently
confronted with problem cases where the doctor
has been over-anxious to do some operative" pro-
cedure. I believe we fail to realize, even though
x-ray shows evidence of union, a splint is desir-
able; splinting by some type of capable, efficient
splint which will take away and prevent, the bone
from bending. This has been shown by Dr., Car-
ruthers. These eases frequently bend arid although
we get excellent position the angulation shown is
a common occurrence. I do not believe we realize
that the six or eight week period is for primary
healing of callus and actual process of healing re-
quires one year or more. The first callus we see
is not the final and result of healing. It is the
initial healing. At a later date natiire- 'takes this
away and reforms callus in a line comparable with
normal callus. This takes about one ^year.

o

CHEMOTHERAPY, LOCAL AND SYS-
TEMIC, AND ITS RELATIONSHIP TO
THE FUNDAMENTAL REQUIRE-
MENTS OF COMPOUND
FRACTURES*

H. WINNETT ORR, M. D.

Lincoln, Nebraska

Any discussion of fundamental require-
ments in the treatment of infected wounds
and compound fractures should 'begin with
a clear statement as to the work of Joseph
Lister. Prior to the time of Lister, certain
fundamentals of surgical practice in this
field had become very well established. The
arrest of hemorrhage, drainage of infected
wounds, and even 'mmobilizaCon and rest

202

Orr — Compound Fractures

in correct position, were employed regular-
ly by many good surgeons. It was Lister,
however, who recognized the significance
of the work of Pasteur, and who understood
for the first time the relationship of germs
to wound infection and the surgical treat-
ment of wounds and compound fractures.
Some others had indeed attempted to treat
infections by other chemicals and even car-
bolic acid, but it was Lister who had the
conception of protecting the patient and his
wound against the invasion of micro-or-
ganisms by the use of carbolic acid as a
chemical barrier against the organic cause
of putrefaction.

This original Lister idea called, of course,
at once for the employment of certain tech-
nics for surgical operations and surgical
dressings. It is in this field of technic,
that we have become confused and that so
often Lister’s original idea of excluding in-
fection has been lost sight of in the search
for a cure for wound infection.

I could quote thousands of instances of
this disregard of Lister’s fundamental
teachings. The following is from a paper
in 1920, by Edward Adams: He says, “In
large infected wounds at the end of the
third day the Carrel tubes were inserted,
and the wound kept wet every two hours
with the instillation of Dakin’s solution.

“Usually beginning at the end of a week,
bacteriological counts were made in order
to determine progress and when the count
reached one microbe to a field or less and
remained this way for three successive
days, the wounds were ready for a second-
ary suture. In most of these cases we got
primary union, but we found after some
experience that if any secondary operations
were attempted before six months after the
original injury had elapsed nearly all of
these cases became secondarily infected
with the Streptococcus hemolyticus.”

Here, Lister’s instructions regarding ex-
posure of the wound, the application of
chemicals to the wound surface and the en-
closure of septic organisms in the wound,
have all been disregarded. Actually, Lis-

*Presenfced at the New Orleans Graduate Medi-
cal Assembly, March 9, 1944.

ter’s original teachings were sounder as to
the prevention of wound infection, than
many like the above that have been prac-
ticed since his time. Lister’s original “anti-
septic system” involved fairly simple, not
very frequent dressings designed primarily
to keep germs away from wound surfaces,
and to protect the patient against irritation
by chemicals, instruments, foreign mate-
rials, and even the surgeon’s fingers. Lis-
ter was very emphatic in saying that car-
bolic acid should never be applied directly
to the wound surfaces. While Lister knew
nothing of sterile gloves, gowns, masks, or
even changes of street clothing, for the op-
erating theatre, he became more meticulous
as he approached the patient and the wound
surface. Chemicals were kept out, dress-
ings were simplified, the wound surface was
covered by a mackintosh, and even the sur-
rounding skin was prepared to avoid the
access of infectious organisms to the wound
itself. Lister was very careful as to his
own hands, and because air always had
access to the wound, he adopted the car-
bolic acid spray, thinking to sterilize the
atmosphere in the wound vicinity. Lister
later confessed his mistake as to the use of
the spray. Unfortunately, he abandoned
also some of his other teachings and began
to use chemical gauze in the wound and even
rubber tubes and horse hair wicks for
drainage purposes. These were allowed to
lie in the wound and to be withdrawn and
re-inserted carrying in then, as they have
ever since, new infection. Tubes have often
been shown to encourage germ growth in
wounds just as they do in the laboratory.

In a recent article, David J. Lewis, (Illi-
nois M. J., 78:530, 1940) arrives at a set of
conclusions upon which I shall comment in
some detail. Lewis says, “An infected
wound should never be closed.” I entirely
agree. To cover over or sew up pockets of
infection in a wound, regardless of the ap-
plication of chemical antidotes, is never
sound surgery. Lewis says further: “1.
Debridement — In any contaminated or in-
fected area this is essential.” As I have
pointed out on many occasions, debridement
and drainage should really mean the same

Orr — Compound Fractures

205

thing. Debridements have often been car-
ried much further then necessary. It is un-
desirable to carry wound excision to the
point of removing quantities of healthy
tissue, or even damaged tissue that may be
useful in wound repair.

Philip Wilson has called our attention to
the point, that in French, debridement
means “to unbridle,” as one might do with
a horse; taking off the accoutrements, but
no part of the horse himself. This is so ob-
viously a fundamental surgical requirement
for every infected wound and compound
fracture, that it should be accepted uni-
versally. Lewis says further: “2. The

wound should be left open and Dakin’s
dressing, or some modification of Orr’s
technic should be employed.” This is a con-
tradiction. Lewis undertakes to combine
or distinguish between a single item of
wound dressing technic like the Dakin
method, and my program in which all tech-
nics are relegated to second place. I have
always demanded conditions with which
actually the Carrel-Dakin treatment would
interfere. Statements like this lead me to
think that details of technic are often mis-
understood as to their relationship to my
program. I should always forbid Dakin
dressings, or any other form of frequent
wound exposure or irritation. Such tech-
nical methods cannot possibly be reconciled
with the immobilization and infrequent
dressing Orr method.

Lewis calls: “3. For immobilization and
elevation of the limb ;” here again we are
dealing with a fundamental requirement for
every injured and inflamed extremity. But
varying degrees of splinting, traction, and
elevation are commonly misunderstood to be
true immobilization. Immobilization should
always mean that kind of fixation in correct
length and position, which protects the pa-
tient against muscle spasm, improper mo-
tion, and irritation or exposure of the in-
flamed parts. A swinging limb in a Balkan
frame with weight and pulley or elastic
traction does not provide this kind of pro-
tection.

Lewis calls next for — “4. “Cultures from
the wound.” This is a technical detail of no

real importance whatever. A well drained,
aseptically dressed, immobilized wound or
fracture will not require culturing except
under the most unusual circumstances.
There is little to be gained by it, and there
is the risk of wound exposure, mixed infec-
tion and disturbance of the patient. In the
next paragraph Lewis says: “5. There is
no need for routine antiseptic treatment.”
I believe we have arrived at this point al-
ready, although in No. 2 you will recall that
he indicated his willingness to accept Dakin
dressings, which is of course, a contradic-
tion and wrong in my opinion.

Lewis requests that the “patient’s gen-
eral condition be kept up.” As to this it has
been my experience that no patient whose
wound is well dressed, who is protected
against secondary infection, and who is im-
mobilized properly in correct position needs
very much in the way of medication or a
special diet. If his physiology in the dam-
aged extremity has been restored he will be
found to respond to all his normal impulses
in the matter of food, drink, elimination,
blood and lymph circulation, nerve supply,
and that sort of thing. With satisfactory
restoration of the local physiology in the
injured or inflamed part the patient’s gen-
eral physiologic processes have a very satis-
factory way of taking care of themselves.

If we choose to think, however, that some
chemical is going to act as a germicide or as
a bacteriostatic (whatever this is!), we
should at least endeavor to provide those
conditions as to asepsis, drainage, and im-
mobilization, in correct position, under
which the “magic cure” may operate with
the greatest assistance from the patient
himself.

As I have suggested, there was a confu-
sion in technics, arising during Lister’s own
lifetime that led us into many indiscre-
tions in surgical practice. The outgrowth
of the aseptic method from what Lister
called the “antiseptic system.” was of
course a natural development. Unfortun-
ately, between Lister’s confusion in regard
to the spray, and certain other technics,
German surgeons almost “stole the show,”
as the saying is, because the aseptic method

204

0 RR — C om pound Fractures

was more rapidly and more perfectly de-
veloped in Germany than it was in Lister’s
own work. It can never be doubted that
the original Lister idea gave us the basis not
only for all the clean surgery we are doing
now, but for much more perfect control of
infection both at operation and in dealing
with open wounds, than has ever yet been
successfully attained. Any frequent dress-
ing method is a violation of the Lister “ex-
clusion of infection” idea. If we once un-
derstand that, it is not difficult to decide at
once whether or not a proposed technic is
good or not. For example : in a recent ar-
ticle it is proposed to treat compound frac-
tures and osteomyelitis by prolonged de-
pendent drainage with lucite tubes. Dennis
presents some interesting photographs of
extremities being treated by dependent
drainage through transparent tubes. He
concludes with a report of eleven cases, un-
der treatment for an average of fourteen
months and with less than good results.
Even these eleven cases need not have been
attempted to demonstrate that prolonged
wound drainage through any kind of tube
is poor technic. One can decide without
trial that such a technical method is no
good, because several fundamentals of sur-
gical care are being violated. Mechanical
irritation of the wound, growth of organ-
isms in the tubes, the insertion and removal
of tubes, and the changes of dressings are
ail violations of Lister’s original teachings
with regard to the protection of the wound
and the patient against mechanical and
chemical damage and the introduction of
germs. Although at times Lister did con-
tradict himself in these matters, an indica-
tion of his real appreciation of the principle
involved is shown by the fact that in the
care of Queen Victoria, upon one occasion,
he went back from the railway station and
required the Queen to undress in order that
he might change the adjustment of a pin
in the dressing of an axillary abscess, so
that there wrould be no danger of puncturing
the mackintosh beneath his outer dressing.
Lister taught that even a single puncture
of the mackintosh covering the wound sur-
face might permit invasion of the wound by

new organisms, and lead to new wound in-
fection and other septic complications.

One of the most discriminating teachers
for many years on this point was William
H. Welch, of Johns Hopkins University.
Welch has called attention on many occa-
sions to the danger of mixed infection and
to the measures by which those infections
can be avoided. No other pathologist or
bacteriologist has indicated so clearly or so
plainly the dangers of soiled dressings,
drainage tubes, foreign bodies, and errors
in technic. It was Welch also who forecast
to some extent the role of bacteriophage
and other natural efforts on the part of the
patient to defend himself against infection.
Next to Lister himself, I should say that
a careful reading of Welch’s writings does
more to indicate the relative importance
and unimportance of certain surgical tech-
nics than the writings of any other surgeon.

Let me close with a reference to another
recent paper. This indicates the danger of
confusion as between fundamentals and
technics, in dealing with this question of in-
fected wounds and fractures. In the Mili-
tary Manual of the Surgeon’s General’s Of-
fice for 1943, “The Treatment of Shock,
Burns, Wound Healing,” Whipple submits
what he calls, “our present improved pro-
gram, for dealing with gunshot wounds
and fractures.” The five principal items
he submits are (1) meticulous debridement;
(2) irrigation; (3) application of sulpha
drugs; (4) reduction of the fractured bones
under x-ray, and (5) immobilization by
plaster-of-paris. These are submitted in
that order and it may be presumed that he
considers them of importance in that order.

I should say that the three important
items in his program, (not part of “an im-
proved program”), but of one which I have
been advocating for many years, are (1)
reduction of the fracture, including the soft
parts; (2) debirdement, or a drainage op-
eration, and (3) immobilization by plaster,
(including pins) or skeletal fixation de-
vices, if necessary. We should, of course,
add to this the subsequent and postopera-
tive protection of the patient against infec-
tion. Irrigation and the application of

Shpiner — Status Efidocrinologicus

205

sulpha drugs we should omit entirely as
being of secondary importance, if of any
importance whatever.

Whipple goes on to provide an elaborate
program of eleven items to cover the after
care of these patients in the ward. This
includes the changes of dressings and bed-
ding, apparatus, surgical dressers, and
many other items of technic, practically all
of which may be disregarded if the other
program to which I have referred is insti-
tuted at the beginning. Whipple does not
mention at all the importance of infrequent
dressings or no dressings at all. In many
hospitals now, the program is the same as
it has been at the Nebraska Orthopedic
Hospital in Lincoln. The rule is that no
dressings are to be done in wards. The oc-
casional dressings required by our program
are done in the operating room under con-
ditions exactly the same as, or resembling,
those under which the original operation
has been performed. This has the effect of
protecting the patient against secondary
infection, of greatly reducing the amount
of labor and surgical material involved, of
reducing the total number of dressings from
thousands or hundreds down to a few, and
of securing for the patients a diminution in
suffering and anxiety. There are fewer
complications, earlier healing and a mini-
mum of deformity and disability. The con-
tributions to the savings in labor and
anxiety to the members of the nursing and
surgical staff are too obvious to require
comment.

o

STATUS ENDOCRINOLQGICUS

CAPT. LEONARD B. SHPINER, M.C.,A.U.S.

Camp Livingston, La.

The combined achievement by clinicians
and laboratory workers in relating certain
disease entities to glands of internal secre-
tion has established endocrinology as one
of the basic sciences in medicine. Its fun-
damental precepts, developed almost entire-
ly by scientific experimentation, have
opened new vistas in the development of our
ideas concerning etiology, methods of diag-
nosis, and treatment of many disease en-
tities.

Attempts to interpret endocrinologic
problems have so increased the numbers of
contributions to its literature and have so
extended the discipline that it is no longer
possible for an individual to encompass its
entire knowledge ; nor is it easy at present,
in view of the kaleidoscopic changes, to ob-
tain a balanced perspective in any one of
its limited fields. In seeking for authentic
information it therefore is necessary to sus-
pend one’s judgment when an effort is
made to evaluate justly the mass of seem-
ingly contradictory data. To many, the
technical nature of the subject and the
seemingly disconnected facts and theories
have only served to confuse ; as an unfortu-
nate result, they have become averse to the
utilization and application of endocrinolog-
ical principles for the solution of their
problems.

It is feasible at this time to dispose of
the oft heard controversy as to whether the
contributions originating from the labora-
tory, or those of clinicians, have been in the
main responsible for the evolution of en-
docrinology from a branch of physiology to
a mature status of its own. Seemingly, in
the light of historical evidence, it is illogical
to assign precedence or even to adjudicate
the relative importance of the laboratory
over that of clinical investigation as being
the prime factor for the progress of endoc-
rinology; for both the laboratory and the
clinic, each with its own sphere of activity,
are yet so mutually interrelated and inter-
dependent on one another that such contro-
versial discussions are both futile and ster-
ile. To vindicate further this statement it
is only necessary to consult the views of
one to whom we owe the beginning of our
knowledge of ductless glands, Claude Ber-
nard. In his philosophic treatise on “Ex-
perimental Medicine” he deals at some
length with the limitation of inquiry both
from the experimental and clinical point of
view, and the advantages of putting med-
ical problems to the proof of comparative
study; only through the establishment of a
common bond and unity of purpose can a
solution be efficiently arrived at. Suffice
to say, that since scientific medicine has

206

S H pi N ek — St a tus Endocrinolog icus

elected to follow the permanent paths of
research for the expansion of its knowl-
edge, the intimate affiliation with the lab-
oratory has put it in a better position to
cope with its problems. Laboratory re-
search, then, is elevated to a prominent and
indispensible position; not, however, as an
independent unit as many critics point out,
but rather as a trail blazing pioneer. By
the concentration of its efforts within well-
defined limits and the utilization of the
latest methods and equipment, it furnishes
a means of projecting inquiry into avenues
ordinarily inaccessible to clinicians. This
enables comparative research to fit the
otherwise intangibles into the picture of
disease etiology, diagnosis, and treatment.
Endocrinology has every right to be proud
of its progress. In the few decades of its
existence, the considerable impetus given to
the study of glands of intestinal secretion,
stands as a monument to our era, empha-
sizing as never before what coordination
and cooperation of the various sciences can
really achieve in, accelerating medical prog-
ress.

It is admittedly difficult to maintain a
neutral objective attitude under the con-
tinual pressure of conflicting reports with-
out giving prejudicial consideration to the
literature which tends to support our views.
This biased state can only lead to the
growth of dogma, which in turn will impede
progress. Under the circumstances, criti-
cism of the present status of endocrinology
is warranted, if only it accomplishes the
purpose of making us realize the limitations
of our inquiry, eliminate dogma, and con-
solidate our knowledge so as to put it at the
effective disposal of those who wish to ac-
quire it, perhaps thereby furnishing addi-
tional incentive for more fruitful and orig-
inal investigation. It is hoped that this
objective will be attained by reviewing the
scientific substratum upon which present
day endocrinology rests, analyzing and ap-
praising the strength and weaknesses of
the methods used in the divergent approach
by research worker and clinician to the re-
lated problems in the field. There is no
pretense to an exhaustive survey of the

problem for the magnitude of the task is
beyond the scope of this limited paper.
However, if by laying open to inspection a
panorama of endocrinology, some of the
more obvious discrepancies will be reduced
or entirely eradicated, my efforts would
have indeed been well rewarded.

In general it may be said that when a
laboratory worker is seeking the solution
of a problem he attempts first, by a process
of deduction, to reduce it into simple com-
ponents. The artificial exclusion of what
he considers to be irrelevant factors, en-
ables him through experimental differen-
tiation to keep his inquiry more circum-
scribed.

In the gradual evolution of endocrine
methodology, the fertile imagination and
zeal of the laboratory workers have devised
and applied many ingenious analytic meth-
ods for the solution of these problems. The
following enumeration of methods repre-
sents an arbitrary division and not of pre-
cedence, for the majority of instances it
is necessary to merge them in order to get
a more effective answer to a given problem.
Briefly then, the methods may be divided
into: (1) anatomic, observation of struc-
ture ; gross and microscopic studies of nor-
mal gland tissue to determine its secretory
character; (2) biologic, reactivity of the
animal to introduced substances; (3) physi-
ologic, evidences of functional changes.
These may be subdivided into (a) extirpa-
tion, (b) transplanting gland, (c) injection
active gland principles; (d) feeding gland
substance, (e) stimulation of nerves to a
gland to study the possibility of secretory
control, (f) pluriglandular syndromes; (4)
biochemical, isolation and purification of
active principles and their pharmocody-
namic action; (5) pathologic, correlation of
endocrine syndromes with structural ab-
normalities; (6) humoral control (e. g.
parathyroids). In recapitulation, the guid-
ing postulates which would unquestionably
establish a given gland as one of internal
secretion, but which have not been satisfac-
torily fulfilled in all details by the glands
ot internal secretion are: (a) Histologic
examination shows the gland to be secre-

Shpiner — Status Endocrinologicus

207

tory in character, and the pathologic
changes in the organ are responsible for the
endocrine syndrome; (b) the isolation of
substances from this issue which have spe-
cific physiology and pharmocodynamic
actions; (c) isolation of this product from
the blood and lymph coming from a given
gland.

From a laboratory point of view, the
purpose of subjecting animals to experi-
mental procedures is to obtain an uncom-
plicated objective symptomatology of dis-
ease phenomena. The laboratory investi-
gator is then in the advantageous position
of observing the initial dynamics of a mor-
bid process either to a preconceived experi-
mental objective, or to exitus of the animal.
When the results of these observations are
compared to those of normal animals kept
under identical laboratory conditions,
physio-pathologic deviations due to disease
changes in the experimental animal become
apparent. The advantages then of using
controlled procedures is in the application
of statistical analysis to the problem. The
repeating of an experimental process time
and again with established endocrinologic
methods, subject to verification by others
working under the same conditions, identi-
fies certain glands of internal secretion
with an endocrine syndrome. The statisti-
cal method is of value insofar as laboratory
procedures are concerned, in that it carries
a certain predictability regarding physio-
pathologic changes. Added pharmocody-
namic interest has been created by the bio-
chemical isolation of active gland princi-
ples, or hormones, their synthesis demon-
strated by chemists, the standardization of
these substances in terms of arbitrary
standard animal units for uniform measure-
ment of potency, and the therapeutic ad-
ministration of these hormones to animals
kept under laboratory conditions.

It must be obvious that in the gradual
evolution of endocrine methodology, the in-
vestigators have not attempted to create an
aura of infallibility around their discov-
eries, but rather to minimize the possibility
of error by making painstaking observa-

tions within the narrow confines of the ex-
periment.

However, mere observation of experi-
mental phenomena is not enough. In the
words of Abraham Flexner, “science is a
matter of observation, inference, verifica-
tion, and generalization.” Discoveries may
promise beneficent possibilities, but how
can they really justify themselves, unless
they are put to practical usefulness? The
essential, then, of every form of experi-
mentation is that it should analyze and col-
late, for it is only through analysis and
collation that experimental details are
brought from the realm of laboratory ab-
stractions to clinical application and useful-
ness.

In the evaluation of data, that is “rele-
vant facts and reasonable interpretations,”
there are sources of error to be considered
which to some extent might modify the re-
corded observations. They are: (1) Deduc-
tion: in reducing a problem to simpler
components, can it be certain that the
worker has been dealing with real or sup-
posed factors? If the preconceived premise
rested on an insecure basis, then the ex-
perimental findings may be inconclusive.
(2) Personal: What training, intelligence,
keenness of perception, and mastery of
methods in use were possessed by the inves-
tigator? These attributes, so little known
about, are nevertheless important enough to
merit consideration. (3) Supervision : Are
the devised experimental procedures ade-
quate to answer best the question to be
tested? When in doubt, advice should be
sought from others more acquainted with
the methodology in the field of inquiry. (4)
Induction : Is the worker warranted in
drawing certain inferences from his data,
and fitting them into the complete and har-
monious disease entity?

Since the biologic sciences are on a lower
scale of accuracy and constancy than the
physical sciences, they are more apt to feel
the impinging influences of modern civiliza-
tion. As a result of the mechanization and
speeding up processes so much in evidence
around us, other factors of error have been
introduced which add to the general con-

208

S h pi ner — Status E ndoc) i nologicus

fusion. These are: (1) The postwar pros-
perity has led to an influx of students to
the institutions of higher learning, thereby
increasing the number of workers, labora-
tories, and periodicals. The sacrifice of
quality for quantity has perhaps found
many workers unqualified for the pursuit
of laboratory investigation. (2) Perfec-
tions in technic : The introduction of more
accurate instruments has made possible
more precise determinations of physio-
chemico-pathologic phenomena. This may
or may not modify the interpretation of
earlier observations. (3) Endocrinology,
no less than other sciences, has been sub-
ject to fads. The paramount enthusiasm
today is in the field of pharmacodynamics,
which has given rise in the literature to
many facts, speculations, and predictions,
all of which have borne little fruit. (4) The
increase in laboratory personnel has scat-
tered publications in journals not entirely
devoted to endocrine research. Under the
circumstances of doubtful supervision, the
selection of articles may be of questionable
merit. (5) Rapid communication contrib-
utes to the swift dissemination of discov-
eries. As a result, they may be applied long
before the possible consequences of their
deleterious effects have been properly eval-
uated.

It is apparent from the foregoing state-
ments that the old criteria of respecting
evidence and not authority must be some-
what amended, and adopted with certain
reservations. A research worker must look
beyond the conclusions of a paper, satisfy-
ing himself on the experimental procedures,
observations, interpretations, and minimal
error before adopting certain inferences as
a part of his endocrine armamentarium.
Left to himself, the mass of contradictory
data are apt to cloud his judgment. To
avoid this dilemma his only recourse is to
turn either to journals entirely devoted to
endocrine research, or for guidance to men
eminent in his field of interest. It is there-
fore incumbent on these sources to set
standards of excellence and to furnish for
him an inspiring leadership.

The practice of medicine is exceedingly
complex. As an art it is concerned with a
number of social and extra-scientific ques-
tions which transcend its boundaries. As
a science it is still concerned with observa-
tions and interpretations of disease mani-
festations.

While it is true as knowledge expands
specialization must of necessity contract,
nevertheless clinical endocrinology at pres-
ent is far from a circumscribed specialty.
Its wide ramifications into the domains of
almost every specialty of internal medicine
has made delineation of the two very diffi-
cult. It follows then that a clinical endo-
crinologist in order to maintain a high
standard of proficiency, must not. only be
basically an able internist, but he must also
be alert to laboratory and clinical discover-
ies; to know the value and limitations of
scientifically proved measures, and to use
them to the fullest extent in deciding diag-
nosis, prognosis, and treatment* of endo-
crinopathies. This he must attempt to do
to fulfill his obligations as a physician.

Not being ordinarily justified in submit-
ting human beings to experimental condi-
tions, he must reach his objective by re-
sorting to the compensatory procedures of
cross examination regarding history, and
record symptoms to establish criteria of
functional changes. Having reached the
limits of detailed examination by the senses,
a use is then made of a number of clinical
instruments of precision. The laboratory
is also sought as an adjunct to diagnosis.

As the fundamental sciences have contrib-
uted a mass of scientific determinations,
with a wide field of application, it became
necessary for the physician to broaden the
scope of his training in order to be1 able
to interpret, correlate, and utilize the find-
ings of the laboratory for a given patient.
The careful control of clinical studies by
necropsy findings, the introduction of sup-
plementary devices as aids to diagnosis, and
the study of active patho-physiologic dy-
namics of morbid processes, have given re-
newed impetus to the progress of internal
medicine. Since the physician deals pri-
marily in human relationships, he has at

S h pi N er — S tat us Endow 'h tolog icus

209

times neglected this phase of practice by
laying undue stress on the question of diag-
nosis.

The subject of clinical endocrinology is
so intricate that even the most enthusiastic
exponents shrink from dogmatism. In or-
der to clarify our ideas, let us by a process
of dissociation approach this subject from
the clinical standpoint of diagnosis, treat-
ment, and prognosis, paying attention to the
similarity in methodology to the laboratory,
the accumulation of information not ordi-
narily accessible to the laboratory investi-
gator, and the completion of the composite
picture of an endocrinopathy.

DIAGNOSIS

A careful history is a means of discern-
ing both the subjective and objective dy-
namics of a disease process. This is some-
what analogous to the initial laboratory
procedures, in that the control period rep-
resents the stage before the onset of symp-
toms, and the progression of the morbid
process is evidenced by present history.
However, certain relevant factors make
their appearance which may obscure or un-
duly emphasize the operating influences of
the disease, namely, the patient’s psychic
reactions as evidenced by exaggerated men-
tal or emotional states.. Separation of the
patient’s reaction to his environmental in-
fluences (social, sex, economic) from that
of the patho-physiologic changes may result
in subsequent errors of clinical judgment.
It is only through the harmonious relation-
ship (an indefinable quantity) between en-
docrinologist and patient, that a proper se-
lection of the characteristic and essential
features of a disease can be made. A proper
evaluation as to the relative importance of
these factors would not only be instructive
to the clinician, but also assure him the co-
operation of his patient.

The recording and classification of symp-
toms not lending itself to precision repre-
sents a difficulty in itself. Different from
the laboratory investigator who through
controlled procedures has induced the dis-
ease and observes an uncomplicated symp-
tomatology, the endocrinologist is faced by
a multitude of physical and mental com-

plaints, depending on age, sex and chron-
icity of the disease. Since the endocrine
glands are in intimate relationship with the
nervous system, in a manner not fully un-
derstood at present, the endocrinologist
must retain the following possibilities in
regard to- their behavior : (a) emotional fac-
tors may either express themselves in psy-
cologic terms giving rise to subjective expe-
riences; (b) in patho-physiologic terms of
structural changes; (c) they may be in op-
eration long enough to cause so-called func-
tional changes in the endocrine system.
Further, chronicity of the disease is of im-
portance in that long standing pathology,
and the resultant endocrine imbalance may
produce changes in several glands of in-
ternal secretion, with an ensuing pluriglan-
dular syndrome. Even should a necropsy
be obtained, he must rule out the possibility
that functional anatomic changes may have
resulted from the reaction of the gland to
morbid processes elsewhere. At present,
due to the above difficulties, only sporadic
attempts have been made to accumulate en-
docrine anthropometric data, which are so
essential to the classification of a disease.
The question then arises whether there is
justification for the use of statistical analy-
sis in disease with so many variables (age,
familial, e.g., Lawrence-Moon-Biedl syn-
drome, sex, chronicity, psychic factors) to
be considered. The difficulty in applying
statistical observations to clinical endocrin-
opathies lies in the fact that there is an
indeterminate starting point, and the diag-
nosis of the disease state may not be uni-
formly established by other qualified endo-
crinologists. In the hands of the laboratory
investigator who can regulate his variables
with controlled procedures, this type of data
is invaluable. However, the clinical appli-
cation of statistical analysis to patients and
the inferences drawn from this method
should warrant the closest scrutiny.

The patient is then subjected to an exami-
nation in which clinical instruments are
used to establish measurable objective de-
tails. Laboratory determinations are also
made to establish the inner- mechanism of
disease. The accumulated data, are then an-

210

ShPiner — Status Endocrinologicus

alyzed with the view of interpreting the
patho - chemico - physiologic changes in a
given patient. Again, it should be empha-
sized that in so far as clinical endocrinology
is concerned, the laboratory findings should
be an adjunct to diagnosis and not super-
sede the clinical impressions to be obtained
from the patient.

TREATMENT

Before instituting any form of therapy
and accurately judging its effects on a given
patient, the clinical endocrinologist must
eliminate certain age-old empiricisms be-
fore drawing unbiased conclusions as to the
results of his treatment. (1) In the ma-
jority of human ills there is a tendency to
improve, and the administration of any
medicine will thus be followed by impi’ove-
ment. It may be feasible to assure oneself
that the specific remedial measures and not
the ordinary succession of events were re-
sponsible for the improvement. (2) Sug-
gestive therapy whether used deliberately
or indirectly is an important factor in ther-
apeutics, and in the field of endocrine ther-
apy it is no less important.

Though the author is well aware of the
beneficial medical as well as the surgical
procedures in use for the amelioration of
endocrine complaints, the indiscriminate use
of organo-therapy as outlined by the detail
man, has aroused protests and condemna-
tion from many quarters of the profession,
to the extent of overlooking its valuable
assets when judiciously administered.

It is to be admitted that at present endo-
crinology is not a restricted field ; there-
fore many clinicians only superficially ac-
quainted with its basic principles feel free
to treat patients with endocrine complaints.
In the present enthusiasm for the adminis-
tration of hormones in endocrine as well as
non-endocrine diseases, the arbitrary guides
to treatment, namely; (a) established diag-
nosis; (b) control of psychic factors; (c)
indications for substitution or stimulative
therapy; (d) acquaintance with the advan-
tages and limitations of hormone therapy;
(e) potency and dosage of hormones sub-
ject to individualization; (f) possibility of
anti-hormone effects have not been adhered

to. The resultant confusion in the field of
organotherapy has made conservative clini-
cians skeptical as to the efficacy of hormone
administration on patients. The achieve-
ments of this phase of endocrinology as
judged by rigid scientific standards are
few, yet the possibilities still remain limit-
less. In the opinion of the author the fu-
ture progress in the field of organo-therapy
will be dependent upon the re-evaluation of
its resources, established indications for
usage, and the scientific detachment in not-
ing its effects.

PROGNOSIS

Since there are so many variables, an ac-
curate prognosis as to the dynamics of a
disease process is difficult to render. How-
ever, the following influences must again
be reiterated for consideration: (1) chron-
icity of the disease; (2) age; (8) sex; (4)
understanding of the physio-chemico-path-
ologic factors involved; (5) intelligent han-
dling of a patient and the understanding of
his specific problem; (6) basic knowledge
regarding the therapy in question; (7) a
follow-up system in order to evaluate the
results of the ti-eatment over a period of
time, particularly when concomitant or-
ganic disease complicates the endocrino-
pathy.

The clinician no less than the laboratory
worker must guard against the unequivocal
acceptance of conclusions. He, too, in the
pursuit of a solution of his pi*oblem is sub-
ject to the same sources of error which may
cast doubt on his clinical reasoning. How-
ever, it is not possible to calculate the ex-
tent of error with any degree of mathemati-
cal certainty, since it is difficult to evaluate
scientifically the uncomplicated effects of
therapy.

In recapitulation, let us again note the
effect of merging of the laboratory and clin-
ic facilities for the solution of endocrine
problems.

LABORATORY

(1) . Start with a normal animal.

(2) . Induce physio - chemico - pathologic
changes with controlled procedures.

(3) . The dynamics of a disease process
with its uncomplicated symptomatology are
closely charted.

Nicoll — Blood Transfusion Substitutes

211

(4) . Statistically repeated. Can predict
morbid changes.

(5) . Biochemical methods used in the iso-
lation and standardization of hormones.

(6) . Having established dosage, pharmo-
codynamic changes can be approximately
evaluated.

The process of analyzing and collating
the above data makes possible its utilization
by the clinical endocrinologist.

CLINIC

(1) . Conversely tries to explain subjec-
tive and objective symptomatology on the
basis of patho-physiologic function, thus
furnishing scientific proof for the experi-
mental observations noted in the laboratory.

(2) . Clinical instruments and laboratory
determinations are scientific aids in record-
ing and classification of disease.

(3) . Treatment with products isolated or
synthesized and standardized by uniform
laboratory procedures again furnishes the
clinician a means of confirming the discov-
eries originating from the laboratory.

The inferences to be drawn from the fore-
going generalizations are that clinical ex-
ploration and laboratory investigation are
equally necessary in arriving at a final so-
lution of a problem. Further, that the lab-
oratory and clinic are only purveyors of
provisional approximation to the truths,
representing the best they can do with the
knowledge at their disposal.

CONCLUSION

If undue attention has been drawn to dis-
crepancies, and errors magnified, it is hoped
that a healthy skepticism would be main-
tained regarding the acceptance of the va-
lidity of theoretical considerations. The
complexities of the subject are simplified,
and a balanced perspective in the field of
endocrinology is maintained only through
the understanding of basic physiologic prin-
ciples and methods of approach to endocrine
problems.

Grateful acknowledgment to suggestions by Dr.
Arno B. Luekhardt, Dr. Anton J. Carlson of the
University of Chicago, and Lt. Col. O. J. La Barge,
is made.

BLOOD TRANSFUSION SUBSTITUTES :
PRESENT STATUS
GORDON A. NICOLL, M. D.

New Orleans

INTRODUCTION

Recent years have seen the advent of
considerable experimentation with blood
transfusion substitutes. The word plasma
has become as well known among the laity
as among the medical profession. The ef-
fects of plasma are conceded to be equal,
and frequently superior, to the effects of
whole blood.

The subject of blood substitutes has be-
come prominent recently because of the
present world conflict. Physicians for many
years, however, have recognized the value of
blood transfusion, and many substitutes
have been proposed and used. In 1878, for
example, a Dr. Thomas enthusiastically pre-
sented a paper on “Intravenous Injection
of Milk” as a substitute for blood. Thomas
felt that, because of its resemblance to
chyle, milk would be as efficacious as blood
yet free from its many dangers in trans-
fusion. He proposed that “the cow should
be milked at the door of the patient’s resi-
dence, by clean hands, into a clean pail cov-
ered with fine gauze.” The effects of this
procedure were “often quite unpleasant
and even alarming” with a rapid pulse and
“respiration of a sighing character.”
Thomas felt that these effects denoted a
“profound impression upon the nervous
system.” Six patients were treated with
milk infusion by Thomas and five of them
lived — probably not because of the therapy
but in spite of it.

Because whole blood, even when citrated,
deteriorates rapidly and must be matched
before it can be used, there has been a per-
sistent search for a practical substitute.

Taylor and Waters have suggested that a
fluid, to be adequate as a blood substitute,
should meet the following requirements: It
should be non-antigenic, non-toxic, cheap,
easily prepared and available: it should be
near the viscosity of whole blood, not leave
the blood vessels too rapidly, and be nearly
isotonic with the red blood cells.

It is the aim of this paper to present a re-
view of blood substitutes up to their present

212

Nicoll — Blood Transfusion Substitutes

status. It is well to note that some of these
ai*e not mere substitutes but are well recog-
nized as having great therapeutic value in
themselves.

GUM ACACIA

Gum acacia was one of the earliest
widely-used blood substitutes. From 1916
until the present time it has been a method
of combating shock. Morowitz, in 1906,
demonstrated its effectiveness in the res-
toration and maintenance of circulating
blood volume. Baylis restored its waning
popularity during World War I, where it
was used extensively. The consensus today
is that gum acacia has an antigenic action,
causes liver damage, and does not supply
the body with the protein it needs; thus it
has fallen into disrepute.

CRYSTALLOIDS

Though long used as blood substitutes
these substances do not adequately meet the
desired requirements. Saline and glucose
solutions are efficacious when salt and wa-
ter are needed by the body but are of little
value in shock or hemorrhage, the condi-
tions from which the main need for blood
arises.

GELATIN

Gelatin-saline solutions were also used
during World War I but were discarded
when found to produce intravascular clot-
ting and to have an antigenic factor.

Within the last year, however, Parkins,
and others, have produced experimental
data which may renew the interest in this
blood substitute.

These workers used calcium gelatinate
made from collagen of bovine long-bones
in a 6 per cent concentration in 0.85 per
cent saline solution. They used dogs as
subjects and found no serious toxic effects
after repeated infusions of gelatin-saline
in normal animals. Liver and kidney func-
tion remained unimpaired. However, a
pseudo-agglutination of red blood cells and
an increased sedimentation rate occurred.
Tissue changes were more pronounced
than with plasma but were reversable.

Following controlled hemorrhage and
standardized burns, three groups of dogs

were treated with plasma, saline, and gela-
tin-saline respectively. The plasma treated
animals showed the best recovery rate, and
the gelatin-saline group was next.

Parkins and his co-workers believe that
a certain factor in plasma which accounts
for its ability to maintain blood pressure
during the secondary or toxemia stage of
shock is lacking in gelatin-saline prepara-
tions. If this unknown factor were added,
they believe, gelatin would be an adequate
plasma substitute.

It is obvious that the status of gelatin as
a blood substitute is undecided. The ma-
terial is of apparent value in the early
stages of hemorrhagic shock and probably
as a post-operative prophylactic. Never-
theless, further clinical investigation is
necessary before its use in this field can be
established.

ISINGLASS

This substance, also a gelatin, is pre-
pared from the swim bladders of certain
fish. Several Canadian groups have in-
itiated the investigation to determine its
value as a substitute for blood.

Taylor and his group found that isinglass
was valuable in the treatment of patients
who have had an acute hemorrhage.

They noted no antigenic action of the
substance. No kidney or liver abnormali-
ties were caused by repeated injections of
isinglass into experimental animals. This
collagen has a pyrogenic action, however.

The pyrogenic action was also noted by
Pugsley and his co-workers. They found
a moderately severe febrile reaction occur-
ring in a small percentage of patients given
isinglass.

Pugsley’s group used a 4 to 7 per cent
concentration of purified, powdered isin-
glass in saline. They found isinglass of
value in shock therapy and feel that it is
a safe blood substitute.

Though further clinical studies must be
made before its use can be accepted, the
potentialities of isinglass-saline as a blood
substitute are great.

ALBUMIN

Human albumin has recently ;found a
place in Military Medicine. Because ad-

Nicoll — Blood Transfusion Substitutes

213

burain is 62 per cent of the total protein of
plasma and has other desirable features of
plasma, namely solubility and stability, it
is being used in a concentrated form to com-
bat shock. It maintains osmotic pressure
very effectively and draws fluid into the
circulation causing the hemodilution desir-
able to offset shock.

However, to administer this substance
without supplementing fluid is thought by
some to be dangerous. Necheles warns
against any concentrated solution (whether
it be serum, plasma, or albumin) in severe
shock or hemorrhage, because it draws
fluid from already dehydrated vital areas.

Plasma or some other fluid should follow
the injection of albumin. The latter must
be considered as purely a first-aid treat-
ment.

Newhouser and Lozner rightly believe
that serum albumin should not be consid-
ered a substitute for plasma or whole blood.
As Henderson has pointed out, there is
a potential military use for albumin because
its compactness facilities transportation.
However the difficulty in preparing it plus
the facts that it is inferior to plasma and
is more dangerous in its action prohibits
its widespread use in civilian life.

PECTIN

Much interest has been aroused recently
by the use of pectin as a blood substitute.
Strictly speaking though, pectin is of little
value as a substitute for whole blood, but is
valuable as a substitute for plasma.

Meyer and his group in Chicago have
been the latest observers of pectin solutions.
This substance is an acid derivative of
citrus fruits. In Ringer’s or sodium chlo-
ride solutions 1.5 per cent of pectin has a
viscosity slightly less than that of whole
blood and exerts slightly greater osmotic
pressure than plasma. The acid solution
must be buffered with sodium phosphate
or lactate to a pH of 7.2 before adminis-
tration.

Clinically, it has been found to relieve
permanently the majority of patients to
whom it has been gi ven as a means of com-
bating not too severe cases of shock. Blood

pressure has been significantly raised and
sustained for twenty-four hours in the aver-
age clinical case of shock. In treating shock
the desirable effect of hemodilution was
obtained by pectin infusions and was main-
tained at least twenty-four hours. Re-
peated administration of pectin brings on
no untoward reactions; yet no additional
improvement results in the patient who has
not sufficiently improved initially.

Aside from a possible pyrogenic action,
no systemic or local toxic manifestations
have resulted from intravenous administra-
tion of pectin. It is eliminated by the kid-
neys within five days of administration,
and apparently has no antigenic effect.

The increased sedimentation rate pro-
duced by the hemodilution resulting from
pectin administration does not contraindi-
cate its use. The beneficial results of the
substance in the treatment of shock are due
to an increase in plasma volume and to the
maintenance of osmotic pressure. Plasma
itself produces the same phenomena ; so the
true value of pectin is in emergency con-
ditions as a substitute for unavailable
plasma.

As a plasma substitute pectin has prob-
ably the greatest potentialities of any sub-
stance excluding the blood derivatives.

RED CELL SUSPENSIONS

So far I have dealt with those substances
used primarily in the treatment of shock/
hemorrhage, and burns. These conditions
are undoubtedly the most important in
which blood transfusion or plasma is need-
ed. However, pectin, albumin, gelatin, or
even plasma would be of very little value
in the treatment of anemias where the main
problem to be dealt with is a lack of the
solid elements of the blood.

With this condition principally in mind,
much investigation has been carried on in'
recent years concerning red blood cells in
concentrated suspensions or in nonplasma
solutions.

The Russians were among the first to use
red cell suspensions. They, as do we, pro-
duce plasma for military use on a large
scale. Red blood cells are a by-product of

214

Nicoll — Blood Transfusion Substitutes

plasma preparation and the USSR has made
use of this by-product for some time.

Their preparation is known as “I.P.K.”
solution and is a suspension of discarded
red cells, from plasma preparation, in a
solution of magnesium sulfate, potassium
chloride, and sodium chloride. Apparently
they have had excellent results in the treat-
ment of blood dyscrasias with this prep-
aration.

Evans, Alt and his group, and Murray
and his co-workers have done a great deal
in investigating and popularizing the use of
red cell suspensions in this country.

Red cell suspensions have been used in
all types of anemias, in leukemias, in hem-
orrhage, in nutritional deficiencies, in ne-
phritis, and in cirrhosis of the liver with
results equalling or bettering whole blood
transfusions. Unfavorable reactions occur
less frequently than with whole blood ti-ans-
fusions.

The practicability of giving large quan-
tities of cells rapidly ; the factor of the small
fluid volume, which is essential in cardiac
cases; and the economy of procuring the
red cells, due to the availability of plasma
are the advantages of red cell suspensions
over whole blood.

The inconvenience of matching the
donor’s cells with the recipient’s serum is
acceptable because there is rarely an emer-
gency existing when this substance is
needed.

It has been found that the addition of
only a small amount of isotonic saline to the
packed red cells is needed to facilitate their
flow through the needle into the recipient’s
vein.

Like whole blood the red cell suspension
is not stable for long. Best results are ob
tained if the cells are infused within three
days after they have left the donor, during
which time storage at 4-6° C. is desirable.

Obviously the infusion of red cell suspen-
sions is not only a good substitute for whole
blood transfusion but is a good method of
treatment in its own right.

MISCELLANEOUS SUBSTITUTES

Many agents have been proposed and
used as blood substitutes with more or less

success. Among this group is ascitic fluid.
This fluid requires typing because it has
specific agglutinins, and it may cause re-
actions. The supply is not dependable, and
it is limited. Though still in the experi-
mental stage ascitic fluid offers no great
potentialities as a practical blood substi-
tute.

The administration of amino acids pro-
vides a direct way of correcting protein de-
pletion and has been shown to be of value
in treating experimentally induced shock in
dogs.

Bovine albumin and plasma have been
used with good therapeutic results. How-
ever, both cause sensitization of the patient
to bovine protein. Recent investigation by
Dunphy and his co-workers indicates the
possible value of small amounts of concen-
trated, purified bovine albumin in the first-
aid treatment of shock.

Hemoglobin-Ringer’s solution has a po-
tential value. An osmotic pressure higher
than that of plasma can be exerted by this
combination, and it also has an oxygen car-
rying capacity. The procurement of hemo
globin would necessitate the procurement
of red blood cells and plasma, however, and
both of these are superior therapeutically
to hemoglobin-Ringers per se. If only
hemoglobin is needed, this combination is
of value.

The Swiss have experimented lately with
muscle extracts, the value of which as a
blood substitute is doubtful.

Recently the Germans have perfected a
synthetic colloid composition called Peris-
ton. This has a high molecular weight and
a strong affinity for water. It raises and
maintains the blood pressure and blood
volume and is apparently well tolerated in-
travenously. The advantages or disadvan-
tages of this colloid as a blood substitute
are familiar only to the Germans at present.

PLASMA ANT) SERUM

Plasma and serum differ in that plasma
is the fluid portion of blood obtained after
an anticoagulant has been added to whole
blood, whereas serum is the fluid remaining
after a clot has been formed. Serum is
minus the plasma protein, fibrinogen.

Nicoll — Blood Transfusion Substitutes

215

For practical purposes these two sub-
stances can be considered together. Plasma
is used almost to the exclusion of serum in
this country, whereas serum is more pop-
ular in England. More unfavorable reac-
tions are known to occur from serum than
from plasma injection.

The widespread use and knowledge of
plasma make discussion of it almost unnec-
cessary. No salesmanship is needed to
“sell” plasma to the physicians serving with
our armed forces.

Plasma in the dried form is the safest
transfusion medium now available on a
large scale. Not a mere blood substitute,
plasma is an approved therapeutic agent
in itself. Plasma is more effective than
whole blood in the treatment of shock, and
shock constitutes the main need for intra-
venous fluid at the present time. Severe
infections, hypoproteinemic states, some
blood dyscrasias and cerebral edema are all
best combatted by plasma administration.

Three forms of plasma are available to-
day : liquid plasma, frozen plasma, and
dried plasma. The liquid form is kept un-
der refrigeration at from 5-6° C. and is the
most practical form for hospital use. There
is a slow loss of prothrombin and fibrin,
however, making it satisfactory only over
limited periods of time.

The frozen plasma must be kept at from
— 15 to — 20° C., at which temperature it
remains stable indefinitely. The constant
low temperature and the cumbersome ap-
paratus needed are the main disadvantages
of frozen plasma. Its efficacy in war time
is doubtful.

The dessication of plasma is today car-
ried out by what is popularly known as the
“lyophile” process. This procedure in brief
consists of, first, collection of blood from
healthy, adult donors: though the spiro-
chete would die in the processing no luetic
blood is used. The blood is next sent under
refrigeration to processing laboratories,
where centrifugation separates the plasma
and formed elements.

Plasma from fijTy bleedings is then
pooled and a preservative added. The plas-
ma is put into its final container and placed

in a “shelling” machine, which rotates the
container in a freezing bath; and the plas-
ma is rapidly frozen to the walls. The re-
sulting large surface area of plasma facili-
tates the dessication, which is carried out
in a vacuum. There is less than one per
cent final moisture) remaining when the
container is vacuum sealed. Simple addi-
tion of pyrogen-free distilled water makes
the plasma immediately available for use.
No typing is necessary.

This lyophile process yields dessicated
plasma that is stable and retains its thera-
peutic value for at least five years.

Plasma has many practical advantages
over other blood substitutes. It contains
all the blood proteins, and exerts a high
osmotic pressure. Circulating blood volume
is restored and maintained ; thus the hemo-
concentration following shock and burns is
offset.

The amount of plasma to be administered
in each case is an important consideration.
It is safely given in large amounts, how-
ever, 950 c c. having been administered in
one dose with no ill effects.

Jenkins and Schafer have recently pub-
lished a very practical guide for plasma
replacement and whole blood administra-
tion. This is in the form of a chart, which
is based primarily on hematocrit values and
body weight, the two variables most easily
determined under emergency treatment.

An equally easy guide to follow is to ad-
minister plasma enough to keep the plasma
protein level at 6 grams per cent and the
hematocrit between 50 and 55 per cent.

CADAVER BLOOD

Since 1927, the USSR has been inter-
ested in the use of cadaver blood for trans-
fusion.

The primary objections of physicians
when approached with this subject are that
blood from dead bodies contains toxins from
the autolysis of tissues and that it has an
abundant bacterial population.

Russian scientists, led by Shamov, have
offset these objections by showing that
there is no great toxicity of cadaver blood
from autolysis of tissues until thrombi be-
gin to form in the cadaver’s vessels. These

216

Nicoll — Blood Transfusion Substitutes

do not occur until four to six hours post
mortem. True, bacterial flora, in an other-
wise uncontaminated corpse, does invade
the blood and other organs by passage from
the gastrointestinal tract into the portal
system; but, this takes place slowly, even
if the cadaver is not kept at low tempera-
ture, and portal system blood is not used in
transfusions. Therefore prompt removal
of the blood from an uncontaminated ca-
daver would cancel the problems of toxins
and bacterial contamination.

Red and white blood cells retain their
vital capacity and the ability to carry on
their physiological roles if they are removed
from the cadaver within ten hours after
death. Kept at freezing temperatures the
blood, once removed, is usable for ten days
or more.

Cadaver blood, according to Shamov,
shows fewer unfavorable reactions than
blood from living donors. The Russians
believe cadaver blood to have immeasurably
greater safety from the standpoint of dis-
ease spread than that from live donors.
This belief is based on the fact that aside
from serological and bacteriological exami-
nations of the blood itself, the cadaver also
receives a more thorough pathologic and
anatomic investigation inside and out than
could be given a live donor.

The Russian donor is usually a person
who has died suddenly of heart disease or
of a cerebral vascular accident. The blood
is citrated as it is withdrawn from the ju-
gular vein in a closed system using an asep-
tic technic. Up to 4,000 c c. of blood has
been obtained from one cadaver in this
manner. The blood is stored at low tem-
peratures. Naturally it must be matched
with the recipients blood before its use.

Erf, among others in this country, has
advocated the use of cadaver blood as a
source of plasma. He has taken such blood
from an individual who died of heart dis-
ease and put it through a process of freez-
ing and drying similar to the “lyophile”
process described previously. After restor-
ing the plasma to liquid form with distilled
water and injecting it into a patient, he
found that the reactions corresponded to

those occurring when plasma from living
donors is used. No antigenic, hemolytic, or
febrile reaction was noted.

A sufficient supply of cadaver blood could
be obtained in this country from morticians.
It could be used for plasma or red cell sus-
pensions, or it could be broken down to more
basic elements, like albumin and globulin,
and used specifically as needed. Standards
should be established for the technic of
blood collection and processing. Selection
of cadavers as to cause and time of death
should also be standardized. Above all the
realization by the medical profession of the
practicability and desirability of cadaver
blood is necessary to further its usefulness
and availability.

CONCLUSIONS

Several blood substitutes have been dis-
cussed and an evaluation of each attempted.
It is very obvious that plasma is the most
satisfactory all-around blood substitute for
the conditions most often needing intra-
venous fluid.

Red cell suspensions will undoubtedly be-
come the most prominent therapeutic agent
where the solid elements of the blood, and
not blood plasma, are needed.

These two substances go hand-in-hand
as the principal blood substitutes. One is
needed in one condition and the other in
another condition. One is the by-product
in the production of the other. Nothing is
wasted when both are used.

Today adequate plasma is obtained for
the armed forces by patriotic donors. Pre-
vious to the war plasma was obtained from
professional donors and was very expensive.
Unless some program of public donation is
maintained, plasma will again become ex-
pensive, while the need for it will remain.
Without the impetus of the war, I believe,
the people will not be as generous in their
blood donations.

A remedy for this constant threat of
plasma scarcity would be the use of ca-
daver blood. It is my belief that the medi-
cal profession could, through a concerted
effort, familiarize the public to the advan-
tages, and urgent need, of using cadaver

Boyce — Carcinoma of the Stomach

217

blood. Once people are made to see how
much more sensible and humane it is to
take blood from the dead rather than from
the living, superstition and prejudice will
be overcome; and the use of cadaver blood
will be an accepted and common practice.
It should not be too difficult to alter the
public sentiment ; already people are learn-
ing of, and accepting, the transplanting of
cartilage, corneae, and nerves from the dead-
to the living.

Plasma and red cell suspensions of ca-
daver blood would enable the continued use
of these substances as the great therapeutic
agents that they are.

BIBLIOGRAPHY

Alt, H. Li. : Red-cell transfusions in the treatment of
anemia, J. A. M. A., 122 :417, 1943.

Alt, H. L., Taylor, S. G., Ill, Cnstes, D. L., anti Bernard,
F. D. : Red-cell transfusions in the treatment of anemia,
further observations, Surg. Gyn. & Obst„ 78:191, 1944.

Bagdasarov, A. : Blood transfusions in the L". S. S. R..
Brit. M. J., 2 :445, 1942.

Blood Substitutes, Symposium Section, Int. M. Dig.,

42:118, 1943.

Davis, H. A. : Recent advances in knowledge concerning’
blood transfusion, J. Louisiana State University School
of Medicine, 3 :1, 1943.

Dunpby, J. E., and Gibson, J. G., II : The effect of in-
fusions of bovine serum albumin in experimental shock,
Surgery, 14 :509, 1943.

Elman, R., and Lischer, C. E. : Amino-acids, serum, and
plasma in the replacement therapy of fatal shock due to
repeated hemorrhage, Ann. Surg., 118:225, 1943.

Erf, L. A., and Jones, H. W. : Experiences associated
with a transfusion unit in a 700-bed hospital. An annual
survey of over 3,500 administrations of blood and plasma
(dried), Ann. Int. M., 19:1, 1943.

Erf, L. A. : A note recommending the use of dried
plasma obtained from fresh cadaver blood. Am. J. Med.
Sci., 207:314, 1944.

Evans, R. S. : Concentrated red cells as .a substitute
for whole blood in the transfusion therapy of anemia,
J. A. M. A., 122:793, 1943.

Hecht, and W.eese : Periston : a new fluid blood sub-
stitute, Bull. War -Med., 3 :511, 1943.

Henderson, J. : The present status of certain blood sub-
stitutes, collective review. Intern. Abst. Surg,, 76 :1, 1943.

Heyl, J. T., Janeway, C. A., Swadsman, A., and Wojcik,
L. : The use of human plasma .in military medicine. Part
I. The theoretical and experimental basis of its use, U.
S. N. Med. Bull., 40 :785, 1942.

Ivy, A. C., Greengard, H., Stein, I. F., Grodins, F. S.,
and Dutton, D. F. : The effect of various blood substitutes
in resuscitation after an otherwise fatal hemorrhage, Surg.
Gyn. & Obst., 76:85, 1943.

Jenkins, H. P., Schafer, P. W., and Owens, F. M., Jr. :
Guide to replacement therapy for loss of blood or plasma,

Arch. Surg., 47 :1, 1943.

Koop, C. E., XHeteher, A. G., Jr., and Riegel, C. : Some
clinical experience with gelatin as a plasma substitute,
Am. J. Med. Sci., 207:415, 1944.

Meyer, K. A., Kozoll, D. D., Popper, H„ and Steigmann,
P. : Pectin solutions in the, treatment of shock, Surg. Gyn.
& Obst., 78 :327, 1944.

Muirhead, E. E., Ashworth, C. T., Kregel, L. A., and
Hill, J. M. : The therapy of shock in experimental ani-

mals with serum protein solutions. Fate in the body of
concentrated and dilute serum and saline solutions, Sur-
gery, 14 :171, 1943.

Murray, C. K., Hale, D. E., and Shuar, C. M. : Red
blood-cell suspensions in the treatment of anemia, J. A.
M. A., 122:1065, 1943.

Nash, J. F. : Milk by vein, 'South. Med. & Surg., 105 :319,
1943.

Necheles, H. : Physiology of shock and of blood substi-
tutes, N. Y. State J. M., 43 :1601, 1943.

Newhouser, L, R., aud Lozner, E. L. : The use of hu-
man albumin in military medicine. Part III — The stand-
ard Army-Navy package of serum albumin, human (con-
centrated), U. S. N. Med. Bull., 40:796, 1942. .

Newhouser, L. It., and Lozner, E. L. : Practical consid-
erations in the therapeutic use of blood derivatives, N.
England J. M„ 228:671, 1943.

Parkins, W. M., Koop, C. E., Riegel, C., Vars, H. M.,
and Lockwood, J. S. : Gelatin as a plasma substitute :
with particular reference to experimental hemorrhage and
burn shock, Ann. Surg., 118 :193, 1943.

Pugsley, H. E., and Farquharson, R. F. : The clinical
use of Isinglass, Canadian M. A. J., 49 :262, 1943.

Shamov, W. N. : The problem of transfusing the blood
of dead bodies, Acta Med. UP^SS, 1 :484, 1938.

Taylor, N. P>., Moorhouse, M. S., and Stonyer. A. J. :
The use of isinglass as a blood substitute in hemorrhage
and shock, Canadian M. A. J., 49 :251, 1943.

Woodruff, L. M., and Gibson, S. T. : The use of human
albumin in military medicine. Part II — Clinical evalua-
tion of human albumin, U. S. N. Med. Bull., 40 :791, 1942.

O

FURTHER OBSERVATIONS ON
CARCINOMA OF THE STOMACH IN A
LARGE GENERAL HOSPITAL*
WITH SPECIAL REFERENCE TO ONE HUN-
DRED THIRTY-FOUR NON-SURGICAL FA-
TALITIES FROM CHARITY HOSPITAL
OF LOUISIANA AT NEW ORLEANS
FREDERICK FITZHERBERT BOYCE, M. D.

New Orleans

I believe as strongly as any surgeon that
carcinoma of the stomach is curable. I
view with deference and almost with rever-
ence the results being achieved at some in-
stitutions and by some groups in this coun-
try, from the standpoint both of resecta-
bility and of long term survival. I realize
what can be accomplished by total gastrec-
tomy. I am aware that even such formerly
hopeless phases of the disease as carcinoma
of the cardia are now, as the result of ad-
vances in technic, amenable to exploration
and occasionally to resection. Finally, I
know that by a judicious extension of indi-
cations gastrectomy is a possibility even
when the growth has extended to adjacent
portions of the liver and pancreas or has

*Read before the sixty-fifth annual meeting of
the Louisiana State Medical Society, New Orleans,
April 24-26, 1944.

218

Boyce — Carcinoma of the Stomach

metastasized to the regional lymph nodes,
the omentum, and the colon.

In spite of these extremely encouraging
considerations, however, I know that carci-
noma of the stomach is not being cured, and
that it is a fatal disease in the vast majority
of all patients in whom it occurs. I think
that we are deluding ourselves and stulti-
fying ourselves if we cite as in any way
typical of the general results those that are
being achieved at the Lahey Clinic, let us
say, or at the Mayo Clinic, or at the Univer-
sity Hospitals in Minneapolis. On the con-
trary, I am convinced that the unhappy re-
sults at such an institution as Charity Hos-
pital of Louisiana at New Orleans are en-
tirely typical of the true facts in this dis-
ease.

It is interesting to observe that surgeons
from some of the institutions where results
are unusually good are not as encouraged
by what they are achieving as are others
who quote them — and not always correctly
at that. At the Mayo Clinic the percentage
of operability approximates 60 per cent, the
percentage of resectability is something
over 25 per cent, and the mortality of re-
section is now well under 10 per cent.1
These percentages have all shown some im-
provement in the last year or two. Yet
Gray,2 writing from the Mayo Clinic in
1942, called attention to two very depres-
sing facts: (1). An analysis of all patients
treated at that institution from 1907
through 1938 revealed very little difference
between the ratio of operability for the
whole period and for the last 15 years, and
the improvement in the percentage of re-
sectability was so slight as to be almost neg-
ligible. (2). With the possible exception of
carcinoma of the lung, the five-year sur-
vival rates of patients with malignancy in
the more common sites is appreciably lower
in carcinoma of the stomach than in any
other variety of cancer.

STATISTICS OF CHARITY HOSPITAL OF LOUISIANA
AT NEW ORLEANS

On two previous occasions I have reported
representative recent surgical cases of car-
cinoma of the stomach at Charity Hospital
of Louisiana at New Orleans and have at

the same time reported, without critical
analyses, all the cases of that disease han-
dled at the same institution during the pre-
ceding years.34 I found no reason to be
cheerful about gastric malignancy as the re-
sult of either study. I have recently studied
134 non-surgical deaths at the New Orleans
Charity Hospital, 115 of which were veri-
fied by autopsy and 19 of which were diag-
nosed in the coroner’s office. Though I
have found no reason to be cheerful about
this group of cases, either, I think I have
found in them certain lessons which point
the way to improvement.

In the 10 year period ending December
31, 1931, the hospital records showed that
758 patients with carcinoma of the stomach
were admitted to the New Orleans Charity
Hospital. Two hundred seventy-five of
these, 36.2 per cent, were submitted to oper-
ation, with a mortality of 35.2 per cent (97
cases). The non-surgical hospital mortality
during the same period was 30.6 per cent
(148 of 483 cases). During the nine year
period ending December 31, 1940, the rec-
ords show that 1,209 patients with carci-
noma of the stomach were admitted to the
same institution. Three hundred forty-nine
of these, 28.8 per cent, were submitted to
operation, with a mortality of 41 per cent
(143 cases). The non-surgical hospital
mortality during the same period was 25.7
per cent (221 of 860 cases).

In the first series of 200 surgical cases
which I analyzed from the New Orleans
Charity Hospital in 1933, the percentage of
resected cases was 17.5 and the mortality
of resection was approximately 53 per cent.
In the second similar series which I ana-
lyzed in 1941, the percentage of resected
cases was 27.5 and the mortality of resec-
tion was 56 per cent. As the result of these
studies, I concluded in 1941 that of every
30 patients with carcinoma of the stomach
admitted to Charity Hospital, only 10 were
submitted to operation, only two of the 10
were submitted to gastrectomy, and only
one of the two left the hospital alive (fig.
1).

Boyce — Carcinoma of the Stomach

219

ar CUQQlTY UOSPITQL OF- LOUISldnQ AT nEAV ORLPQnS
1922 - 1940

of every 3c paTitnis ddithtted wuw caRcinoma o,- tup STomacu

imifttHimmiHHfiHHii

OflLV 10 WERE SUBITIITTED TO SURGERY ,

QT CUQRlTY U05PITQL Of LOUl5IQnO QT npw ORlPQnS
1941 - 1942

Or EVERY 30 POTIE-TITS QDIDITTE-D WITH CORCinomO Of TUP STOrTlQCU

HHHHHHHiHHHHHHHi

OniY 12 WERE SUBmiTTED TO SURGERY

hhhhhh

OflLV Z Of TUP 10 WERE SUBmiTTEO TO GQ^lRt-CTOfTlV

H

flRO OflLV ± Of TUP 2 LEFT TUP EIOSPITQL CLIVE-

I

Fig'. 1.

BUT 4. Of TUP 12 WERE SUBITIITTED TO GQSTRECTOmv

Hi!

QnD_3_0f TUP 4 IPfT TUP UOSPITQL QLIVE

Hi

Fig. 2.

OOmPOOQTIVt- PPOPORTIOnS Of PESECTQBILITY QtlD mOQTQllTY
ID TUQtE- 5ECIE5 Of 5UPGICQL CQ5E5 Of CQRCinOITIQ Of TUE

sromacu fpom cuqritv uospitql of Louisiana at nPwoRLECins

f_ Y

I

W

■

m

194 L

6fl5TRtCTOmv

*

i

m

l

TOT PL

/ X

m

i

i

costs

DtPTWS

1944

GQSTRtCTOmV

■■■

1

Fig.

It must be granted that for the two year a mortality of 27.3 per cent (26 cases), as
period ending December 31, 1942, the sta- compared with a non-surgical hospital mor-
tistics are somewhat more encouraging (fig. tality of 35.4 per cent (51 of 144 cases).
2). Of the 239 patients with carcinoma of The percentage of resectability for the
the stomach admitted to the hospital, 95 whole series was 12.5 (30 cases) and 31.5
(39.7 per cent) were operated upon, with for the surgical cases. The mortality of re-

220

Boyce — Carcinoma of the Stomach

section, however, had fallen to 26.6 per cent
(eight cases) . The improvement in the mor-
tality of gastrectomy is striking; the pro-
portion of resectable cases, in respect to
both the total series and the surgical cases,
is still far from encouraging. Although we
have greatly improved our surgical per-
formance (fig. 3), we are still not seeing
patients early enough for them to benefit
from the improvement.

To a certain extent the discouraging as-
pects of carcinoma of the stomach at the
New Orleans Charity Hospital can be ex-
plained away. In the first place, although
gastric surgery is always surgery of mag-
nitude, its performance there is not limited,
as it is at private clinics and some general
hospitals, to a small group of highly skilled
and widely experienced surgeons. The com-
bined 400 surgical cases which I have just
mentioned were the responsibility of 62 sur-
geons, many of whom do not confine their
work to surgery and some of whom were
residents performing their first gastric op-
erations (and who, of course, must be per-
mitted to learn gastric surgery under ade-
quate tutelage). As a result, some of the
deaths, particularly in the first series, were
due to frank technical errors.

In the second place, preoperative and
postoperative care often left much to be de-
sired in the 1933 series, though in the 1941
series it was generally good, and in the
cases handled in 1941 and 1942 it was usu-
ally excellent, which explains a large part
of the improvement in the mortality.

In the third place, in the 1933 series re-
section was probably not performed in some
cases in which, if they had been encoun-
tered today, it would have been done, for
gastrectomy, while by no means a surgical
curiosity in the late twenties of this cen-
tury, was still not the common procedure
which it is at this time. In the second se-
ries, as well as in the cases handled in 1941
and 1942, the improvement in resectability
was often achieved by a deliberate, and I
think entirely justified, extension of the
indications.

Finally, the explanation of the depressing
results at the New Orleans Charity Hos-

pital is the obvious one, that these patients
represent the lowest level of financial ca-
pacity, and frequently, though naturally not
always, the lowest level of intelligence and
of hygienic living. On the other hand, my
own experience in the private practice of
surgery has convinced me that the financial
ability to consult a physician without delay,
and to pay for the best in hospitalization
and nursing care, does not produce a very
large number of resectable gastric cancers,
even when financial ability is linked with
native intelligence and exceptional educa-
tional opportunities.

I need not remind you, furthermore, that
the whole picture of carcinoma of the stom-
ach is actually much worse than the figures
from Charity Hospital or from any other
institution suggest. To the patients who
die in hospital, with or without surgery,
must be added certain other patients: (1)
The patients whose growths have been re-
sected, but who die in longer or shorter pe-
riods of time after their discharge; (2) the
patients whose growths prove to be inoper-
able when the abdomen is opened, and the
patients who are not explored at all, since
the mortality in carcinoma of the stomach
in which resection is not done is precisely
100 per cent; (3) the patients who die with-
out their disease being diagnosed during
life and who are not submitted to autopsy.
Any one who has studied even small series
of autopsied cases knows what surprises
they can produce in the way of inaccurate
clinical diagnosis. (4) The patients who
die of carcinoma of the stomach outside of
institutions, a proportion which is estimated
in Saltzstein and Sandweiss’ ' study, for in-
stance, at more than 40 per cent of the total
number of deaths.

An analysis of the 134 non-surgical
deaths recently studied, which occurred in
the years 1930-1942, inclusive, proves cer-
tain of the points which I have just made.
The diagnosis was not made in 11 of the 19
cases examined by the coroner, nor in 45.
of the 115 cases examined by autopsy, that
is, in 41.8 per cent of the 134 cases. In a
number of the remaining cases it was mere-
ly set down as one of a number of possible

Boyce — Carcinoma of the Stomach

221

causes of . death. In all fairness it must be
said that these diagnostic failures were not
always the fault of those who handled the
cases. In the 19 coroner’s cases the dura-
tion of observation was from two hours to
two years, but 15 of the patients died within
a week of coming under observation for the
first time, and 13 of these died within 48
hours. In the 115 cases submitted to post-
mortem examination the duration of obser-
vation was from two hours to three years,
but 30 of the patients died within a week
of coming under observation for the first
time, and 10 of these died within 48 hours.
In the great majority of these fatal cases
the patients had had no medical attention at
all before they entered the hospital in what
proved to be their last illness.

THE ROAD TO IMPROVEMENT IN CARCINOMA OF
THE STOMACH

What lessons are to be learned from these
tragic circumstances? Unless carcinoma of
the stomach is diagnosed, it cannot be
treated. How are diagnostic methods to be
improved? Many of these cases, every one
of which must be set down as a failure in
both diagnosis and therapy, point the road
to improvement.

There must be a much higher index of
suspicion in regard to this disease. It must
be kept in the back of the mind, so to speak,
and brought forth as a possibility in the
unlikely as well as in the likely cases. Let
me illustrate:

Carcinoma of the stomach is most fre-
quent in middle life and beyond, but it is
not infrequent prior to that period, and it
may occur in youth. In the surgical cases
which I studied from the New Orleans
Charity Hospital, one patient in every 10
was under the age at which cancer of any
kind is ordinarily looked for, and negroes
tended to develop the disease at an even
earlier age than white subjects. In the 134
non-surgical deaths which I have just
studied, the age range was from 26 to 83
years, and eight patients were under 40
years of age. Gastrointestinal malignancy
was considered a possibility in two of these
eight cases, but in two patients (35 and 37
years of age) no diagnosis was made, and
the diagnoses in the remaining patients,

who were respectively 26, 32, 33 and 35
years of age, were anemia, duodenal ulcer,
tuberculous peritonitis, and syphilis of the
stomach.

Carcinoma of the stomach must also be
suspected in the presence of a wide variety
of symptoms, many of which bear no ap-
parent relation, direct or indirect, to the
alimentary canal. So wide is the variety,
as a matter of fact, that Moynihan(i was
fully justified when he said that as he read
the histories of a series of patients with
gastric malignancy, he was driven to won-
der whether all of them could possibly
have the same disease.

This series of non-surgical deaths, like
the two surgical series of cases I have pre-
viously studied, perfectly illustrates that
there is no classical picture of early, curable
malignancy of the stomach. The classical
picture is the terminal picture. The first
symptoms in these cases took the form of
dyspepsia, or various kinds of indigestion,
or epigastric, distress, or anorexia, or eruc-
tations, or heartburn, or dysphagia, or
nausea and vomiting. Sometimes the first
symptom was pain, which also took a wide
variety of forms, and which was occasion-
ally so severe and continuous as to suggest
an acute abdominal condition. Sometimes
the illness began insidiously and took the
form of a “decline,” manifested by loss of
weight, which might be extreme, weak-
ness, and lack of energy and enjoyment of
life. Sometimes the onset was abrupt,
with obstructive vomiting or hematemesis
or both as the first manifestation. An oc-
casional patient, as in the case reported by
Gaines7, complained chiefly of dyspnea.
Hiccups were the first symptom in four
cases, and, as I have pointed out previously,
seem to deserve more attention than they
receive. Sometimes the symptoms dated
from a previous unrelated illness, from
which there was never full recovery, or
from a digestive disturbance which, in-
stead of disappearing, became chronic. Two
patients dated their illness from a blow and
a fall, respectively, and another dated his
illness from a kick by a mule. Seven pa-
tients had had digestive symptoms of long

222

Boyce — Carcinoma of the Stomach

duration which had recently changed in
character, and 12 presented a distinct ulcer
syndrome, concerning which I shall have
more to say later.

In some of these cases — and this has been
true in both of my other studies from the
New Orleans Charity Hospital — carcinoma
of the stomach developed in combination
with other illnesses, such as cardiac disease,
genitourinary disease, arthritis (which was
regarded as the cause of death), a cerebral
accident, and cataract, for which an opera-
tion had been performed three months be-
fore the patient entered the hospital to die
of carcinoma of the stomach. A number of
other patients had been treated in the wards
and clinics for varying periods of time be-
fore their final admissions, either with un-
determined diagnoses or on diagnoses of
gastritis, appendicitis, indigestion, syph-
lis of the stomach (two cases) and anemia.

These cases carry their own lessons of
missed opportunities. The first lesson is
that patients in middle life and beyond
should not be dismissed from observation
until a definite diagnosis of their spmptoms,
no matter how vague they may be, is arrived
at. The second is that a patient with one
disease is not immune to the development of
another disease. Many cases of carcinoma
of the stomach might be detected in their in-
cipiency if the possibility were borne in
mind for all patients in the so-called cancer
years who come under observation for any
cause whatsoever. In particular, patients
in this age group with actual or supposed
pernicious anemia should be examined at
regular intervals by means of a barium
meal, since carcinoma of the stomach and
pernicious anemia are frequently associated,
and since many instances of supposed per-
nicious anemia are actually secondary to
malignancy of the stomach. Incidentally,
four of these patients presented double ma-
lignancies, including, in addition to carci-
noma of the stomach, carcinoma of the lung,
of the kidney, and of the prostate gland
(two cases).

While the error was not made in any case
in this series, it might be well to emphasize
that carcinoma of the stomach cannot be

diagnosed on the basis of gastric analyses.
Hypoacidity and anacidity are extremely
suggestive, but the diagnosis is not excluded
by their absence, and neither normal acidity
nor hyperacidity is incompatible with a
diagnosis of gastric malignancy.

Gastroscopy was not employed in a single
case in this series. It was naturally not
used in the earliest cases because it is a
method of recent development. It was not
used in some of the later cases because the
patients died too promptly or were in too
critical a condition to permit the use of a
measure which, in spite of many improve-
ments, is still something of an ordeal. In
the remaining cases, however, it seems not
to have been employed because carcinoma
of the stomach was not suspected. Gastro-
scopy has marked a distinct advance in the
diagnosis of carcinoma of the stomach and
it should be employed in every suspected
case. On the other hand, it should never
be regarded as anything but an adjunct
measure, and it should be disregarded if the
negative findings are not in accord with
the clinical picture.

Roentgenologic examination was carried
out in 43 of the 134 cases, being omitted in
the remainder for the same reasons that
gastroscopy was not employed. In 25 cases
the radiologist reported carcinoma of the
stomach. But in two instances an extrin-
sic gastric mass was reported, in three in-
stances the radiologic diagnosis was du-
odenal ulcer, and in 13 cases the findings
were negative, and, unfortunately, were ac-
cepted as conclusive. To the last group
must be added another case in which, two
years before hospitalization at Charity Hos-
pital, x-ray examination had been carried
out at another clinic with negative findings ;
the patient was then lost from observation
until the illness which ended her life.

Radiologic examination is the most im-
portant single measure in the diagnosis of
carcinoma of the stomach, and Kirklin8
states categorically that human negligence
and not the method itself is at fault if it
does not demonstrate a gastric cancer which
gives rise to symptoms and which can be
demonstrated macroscopically. Such perfec-

Boyce — Carcinoma of the Stomach

223

tion most radiologists do not achieve, and it
is therefore a safe rule to disregard nega-
tive radiologic findings if they are not in ac-
cord with the clinical picture.

Useful as is the x-ray, it does not tell all,
nor should it be expected to. In most cases
it demonstrates the existence of a gastric
lesion, it reveals with great accuracy where
it is located, and it reveals with a high de-
gree of accuracy how large it is. But in
many cases it does not safely differentiate
between benign and malignant lesions, and
in no case should it be relied upon for a de-
cision as to operability. If the radiologist
were held responsible in these regards, says
Kirklin, the outlook would be gloomy indeed,
for he knows that most gastric lesions are
malignant and that most malignant gastric
lesions are inoperable. For my own part,
as I have said before, I should like to see
a return to the type of x-ray report of which
Cole9 spoke with such scorn, “This patient
has a gastric lesion, the nature of which can
be determined only by exploration.”

GASTRIC ULCER VERSUS GASTRIC CANCER

I have long believed that the greatest
field of improvement in gastric malignancy
rests in the exploration, and that without
undue delay, of every patient with supposed
gastric ulcer who is over 45, or, better, who
is over 40, years of age. That is not a
radical point of view, though at first
glimpse it may seem to be. On the diagnos-
tic criteria of long-standing epigastric dis-
comfort relieved by food, alkalis and a bland
diet, and characterized by natural remis-
sions, 25 per cent of the 400 surgical cases
I have previously studied from Charity
Hospital presented positive or possible ulcer
syndromes. More than half of the patients
had been treated- by private physicians, or
in the wards and clinics of the hospital, on
this diagnosis, or had treated themselves
on advice received over the radio or at the
corner drug store. In the 134 non-surgical
deaths, 12 patients presented an ulcer syn-
drome and six had been treated for peptic
ulcer; the numhey, I believe, would have
been larger had it been possible to secure
adequate histories from all of these patients.

The success of therapy in many of these
cases is further proof of Moynihan’s10 ob-
servation that one of the causes of the high
mortality of carcinoma of the stomach is
the successful treatment of supposed gas-
tric cancer which masquerades as ulcer.

These statistics are not unique. In other
reported series the proportions are) fre-
quently higher. Thus Walters” states that
at the Mayo Clinic “the most disastrous ob-
servation” in regard to the symptomatology
of gastric malignancy was that 30 per cent
of the patients gave a history of the ulcer
type, in 10 per cent of the cases submitted
to resection the radiologist had made the
diagnosis of ulcer, and 80 per cent of the
patients with carcinoma of the stomach
who were treated for ulcer had responded
favorably to medical therapy, and thus, it
might be added, had lost much of their
chance of salvation.

Allen and Welch12 have recently published
a particularly conclusive study of ulcer ver-
sus cancer at the Massachusetts General
Hospital. Of 277 cases diagnosed as ulcer
over a 10-year period, 14 per cent proved to
be cancer. Of 175 cases in which medical
treatment for ulcer was employed, 7.4 per
cent proved to be cancer. Of 23 cases in
which gastroenterostomy was performed
for supposed ulcer, 17 per cent later proved
to be cancer. Of 68 cases in which gastric
resection was done for supposed ulcer, 43
per cent proved to be cancer. On the other
side of the picture, of 344 cases in which re-
section or some palliative procedure was
carried out for supposed carcinoma of the
stomach, 5 per cent proved to be ulcer.

From these disturbing figures Allen and
Welch draw certain conclusions to which I
heartily subscribe : (1) When the differen-
tial diagnosis of ulcer and cancer arises, the
question can be settled safely only by ex-
ploration and sometimes not then. (2).
Patients beyond the fifth decade of life with
recent digestive symptoms are five times
more likely to have cancer than ulcer. (3).
The risk of cancer in the prepyloric and
fundal regions of the stomach far outweighs
the risk of surgery for the lesion. (4). Al-
though 50 per cent of all gastric ulcers

224

Boyce — Carcinoma of the Stomach

originate on the lesser curvature, that still
leaves a 50 per cent chance that any sup-
posed ulcer in this region is a cancer. (5).
Although the incidence of cancer increases
progressively with an increase in the di-
ameter of the ulcer, and though a lesion of
2.5 cm. and over is likely to be malignant,
there is no way of determining, in the ab-
sence of exploration, that lesions smaller
than this are not malignant. One cancer in
the series I have just studied from Charity
Hospital was 0.5 cm. in diameter.

The whole acrimonious discussion which
has arisen on the subject of gastric ulcer
versus gastric cancer can be reduced to very
simple terms: (1). Once the possibility of
transition from ulcer to cancer is admitted,
the proportion of cases in which the transi-
tion occurs is merely academic ; the law of
averages is of small assistance when one is
dealing with a single individual. (2). There
is often no possible way of determining,
short of surgical exploration, what condi-
tion one is dealing with in any particular
case. (3). The physician who accepts these
facts will be very sure of his ground before
he undertakes the medical treatment of sup-
posed benign ulcer or supposed functional
dyspepsia after young adult life, even
though he means to employ the treatment
only for differential diagnostic purposes.

THE RESECTABILITY OK GASTRIC MALIGNANCY

The most important and the most tragic
lesson, yet in a sense the most encouraging
phase, of this series of non-surgical cases
is that, from the standpoint of their ma-
lignancy, not all of these patients ought to
have died. In the 115 autopsied cases, eight
of the 42 white patients and 20 of the 73
negro patients presented malignant lesions
of the stomach which could readily have
been resected. Twelve of the 28 died within
two hours to seven days of their admission
to the hospital, and only one patient in this
group had had any previous medical treat-
ment. No responsibility for their deaths
can therefore be laid upon the hospital, or,
except in the single case mentioned, upon
the medical profession, except in so far as

we have failed in our duty to educate lay
persons as to the risks and potentialities of
gastric cancer.

The remaining patients, however, are in-
cluded in a group already mentioned, who
had been previously treated in the hospital
for unrelated diseases or for peptic ulcer
and other disturbances of digestion, or for
symptoms which, in the light of what later
happened, must have been the first mani-
festations of malignant disease.

With only two exceptions these 28 pa-
tients had been admitted to the medical
services of the hospital, a practice which
W. J. Mayo13 inveighed against in 1905 but
which has not changed since his day. On
the other hand, we as surgeons can feel no
special pride in what happened in at least
seven of these resectable cases, in all of
which surgical consultation was requested.
In one instance surgery was stated to be
inadvisable because of the patient’s age
(71) and his cardiac state. In one instance
the advice was to delay surgery until the
effect of antisyphilitic therapy on the gas-
tric lesion could be observed. In two in-
stances only jej unostomy was stated to be
possible, and this the patients, quite under-
standably, refused. In the remaining cases
the malignancy was stated to be inoperable.

Yet from the standpoint of the disease it-
self, the lesion was resectable, not only in
the seven cases for which surgical consulta-
tion was sought but in all of the other 21
cases in this special group, in six of which,
incidentally, the diagnosis was not made.
The location was prepyloric in 18 of the 28
cases, almost two-thirds, this being the most
favorable of all locations for resection, and
there was no instance in the group of carci-
noma of the cardia, which is the most un-
favorable of all locations.

It is true that in 12 cases the growth had
metastasized to the regional lymph nodes,
but such metastases, while they materially
lessen the chances of long term survival, are
no longer a contraindication to resection. It
is true that in one case there was metastasis
to the omentum and mesentery, and in an-
other erosion into the transverse colon and
metastasis to the cecum, but again, though

Boyce — Carcinoma of the Stomach

225

resection of the omentum adds somewhat,
and resection of the colon considerably, to
the surgical risk, these operations can be
carried out together with resection of the
stomach. It is true that in some cases the
growth involved the major portion of the
stomach, but total gastrectomy is a feasible
procedure, even in aged subjects. It is true
that the lesion was sometimes quite large,
but mere bulk is not a contraindication to
gastrectomy. It is true, finally, that some
of the patients were in very poor condition,
or had other diseases, but preparation for
surgery is possible even in hopeless-seeming
cases. Transfusions, infusions, vitamin
therapy, and the use of some special diet,
such as the Varco I and II diets14, frequently
achieve surprisingly good results even when
all the odds seem against success.

The group of cases which I have classified
as resectable does not include, it should
be emphasized, any of the cases in which
extension to the pancreas and metastasis to
the liver were of moderate degree and so
localized that resection might have been
considered. It does include, however, one
instance of perforation, of which, incident-
ally, there were 16 in the 115 autopsied
cases, a very high proportion for an accident
which is generally stated to be infrequent.

The patients in the seven cases in which
surgical consultation was sought died with-
in nine to 43 days of the consultation, and
I am not sure, in view of their generally
poor status, that surgery could have ac-
complished very much. I am concerned,
however, with two facts : 1. That no effort
was made to improve their condition, so that
surgery might have been considered. 2.
That in each of these instances the surgeon,
given the chance for which he is constantly
pleading, and for the lack of which he con-
stantly blames the medical man, either mis-
diagnosed the case altogether or misdiag-
nosed the status of the growth.

In my 1941 report on carcinoma of the
stomach at the Charity Hospital of Louis-
iana at New Orleans I found myself repeat-
ing a good deal which I had said in my 1933
report, and in this report I find myself re-
peating a good deal which I said in both

papers. Certainly these 134 non-surgical
cases prove the validity of my former con-
clusions: (1). Any improvement in the re-
sults of gastric cancer rests first with the
patient. Until he presents himself to the

t

physician no treatment is possible. (2).
The basic problem, when once the patient
presents himself to the physician, is how
soon the physician turns him over to the
surgeon, and how soon the surgeon operates,
on suspicion if he cannot positively elimi-
nate the possibility of gastric carcinoma. I
do not in any way desire to detract from the
heavy responsibilities which are carried by
the surgeon who operates for gastric carci-
noma when I point out that, as matters now
stand, the lessening of those two intervals
seems, at least in public hospitals, to offer
the greatest hope of improving the present
tragic results in this disease.

SUMMARY AND CONCLUSIONS

1. Brilliant results are being achieved in
a small proportion of the cases of carcinoma
of the stomach, chiefly at a small group of
institutions, but the general picture of the
disease is not bright elsewhere.

2. To two series of 200 surgical cases
each studied from Charity Hospital of
Louisiana at New Orleans in 1933 and 1941,
respectively, is added the analysis of a
group of 134 non-surgical fatalities, 115 of
which were studied at autopsy and in 19 of
which the diagnosis was confirmed by the
coroner.

3. Early diagnosis, which is the key to
improvement in this disease, will not be
achieved until it is borne in mind that car-
cinoma of the stomach may occur in younger
persons as well as in the so-called cancer
years; is atypical in many cases and pre-
sents the so-called classical picture only in
the terminal stages; and often occurs in
combination with other diseases, the obser-
vation of which furnishes opportunities
(usually overlooked) for detection of the
malignancy in its incipiency.

4. Gastric analysis may be confirmatory
but is never diagnostic. Gastrqscopy is
useful and roentgenologic examination is
indispensable, but negative findings should

226

Boyce — Carcinoma of the Stomach

not be accepted if they are not in accord
with the clinical picture.

5. The greatest field for improvement in
carcinoma of the stomach lies in the surgical
exploration, without undue delay, of all pa-
tients in middle life with supposed gastric
ulcer. Gastric ulcer usually cannot safely
be differentiated from malignancy of the
stomach except by exploration at this period
of life, and therefore cannot safely be
treated by medical means.

6. In 28 of the 115 fatal non-surgical
cases in which the diagnosis of carcinoma
was confirmed by autopsy, the growths per
se proved to be resectable. Surgical con-
sultation had been invoked in seven of these
cases, in six of which either radical surgery
or all surgery had been stated to be impos-
sible. It is suggested that surgeons need to
develop more boldness in attacking this
disease and should, after proper prepara-
tion, explore any patient in whom the mere
opening of the abdomen would not prove
fatal.

REFERENCES

I. Walters, Waltmau, Gray, II. K., and Priestley, J. T. :
Carcinoma and Other Malignant Lesions of the Stomach,
1042, Philadelphia and London, W. B. Saunders Company.

Gray, II. K. : The diagnosis and treatment of cancer
of the stomach, Surg. Gyne. & Obst., 74 :487, 1942.

3. Maes, U., Boyce, F. F., and McFetridge, Elizabeth
M. : The tragedy of gastric carcinoma. A study of 200
surgical cases, Ann. .Surg., 98 :619, 1933.

4. Boyce, F. F. : Carcinoma of the stomach in a large
general hospital. A comparative study of two series of
surgical cases from Charity Hospital of Louisiana at New
Orleans, J. A. M. A., 117:1070, 1941.

5. Saltzstein, II. C., and Sandweiss, D. J. : The prob-
lem of cancer of the stomach, Arch. Surg., 21 :113, 1930.

0. Moynihan, B. G. : Cancer of the stomach, Practi-
tioner, 121 :137, 1928.

7. Gaines, L. M. : Diagnostic problem of the causation
of dyspnea : Report of a case with autopsy, J. A M A
104 :G32, 1935.

8. ICirklin, B. R. : Mistakes and misunderstandings in
the roentgenologic diagnosis of gastric cancer, Arch Surg
40 :861, 1943.

9. Cole, L. G. : Malignancy of gastric ulcer, Radiology,
12 :4S, 1929.

10. Moynihan, I?. G. : Essays on Surgical Subjects,
1921. Philadelphia, W. B. Saunders Company.

II. Walters, Waltman, and Cleveland W. II.: Results
of partial gastrectomy for bleeding duodenal, gastric, and
gastro.jejunal ulcer, Ann. Surg., 114:481, 1941.

1 -. Allen, A. \Y ., and Welch, C. E. : Gastric ulcer.
The significance of the diagnosis and its relationship to
cancer, Ann. Surg., 1 14 :498, 1941.

13. Mayo, W. .1. : A review of five hundred cases of
gastroenterostomy, including pyloroplasty, gastroduodenos-
tomy and gastrojejunostomy, Tr. Am. S. A., 23 :1G8, 1905.

14. Wangensteen, O. II. : The surgical problem of gas-
tric cancer; with special reference to: (1) the closed

method of gastric resection, (2) coincidental hepatic re-
section and (3) preoperative and postoperative manage-
ment, Arch. Surg., 46 :879, 1943.

DISCUSSION

Dr. Walter Moss (Lake Charles) ; I think Dr.
Boyce is to be congratulated on the splendid re-
view of an apparently hopeless subject at the pres-
ent time. I do not look on it from the standpoint
that it is as hopeless as the statistics point out,
especially if Dr. Boyce continues to persevere and
present these statistics.

There are a few points I want to bring out. One
of these is that the puzzling cases go to the gen-
eral practitioner and run the gamut of several
doctors until the case is obvious and that has some-
thing to do with the bad results which Charity
Hospital has, I am sure. We often see a patient
in private practice with stomach ache or indiges-
tion and he is given belladonna or what not and
finally the case becomes obvious and the patient
changes from one physician to another and the
growth gets out of hand. At the present time the
limit of time for the average physician to give to
his patients, especially those with chronic ailments,
will unfortunately add to disastrous results. I do
not think any of us have the proper amount of
time right now to give to these cases to make
any great improvement in the statistics unless we
give better attention to this type of case.

One helpful suggestion is the establishment of
more adequate facilities at cancer clinics and ex-
tension of services to smaller communities. The
economic problem of submitting the patients with
preliminary symptoms of gastric carcinoma is at
present a problem. The patient comes in with
dyspepsia and at once you are limited by the fact
that you can not submit him at that time to a
complete physical survey. Whether that is the
fault of the physician or the fault of our general
economy, I am not going to attempt to answer.
Some people think that they might have an answer
to it in some various forms of state medicine but
I still think the facilities would not be available
because of the scarcity of specialists in some locali-
ties; roentgenologists, gastroenterologists as well
as the surgeons.

I he greatest work in cancer is now being done
by the state cancer committee and the Woman’s
Field Army, parts of the American Society for
the Control of Cancer. Education of the public
is putting them in mind of noticing symptoms and
insisting on the importance of having more ade-
quate examinations. This is one of the things that
will, I feel sure, decrease the mortality somewhat.

Dr. J. E. Heard (Shreveport): I am especially
inteiested in this type of work and have very
much enjoyed Dr. Boyce’s splendid presentation of
this most important subject.

Gastrectomy on the human being was first per-
formed about 1881, Billroth performing the first

Clinic o -Pathological Conference

227

successful operation. Gastrectomy was attempted
before this date, but the patients did not survive
the operation. Following this, many men per-
formed successful partial gastrectomies with the
technic fast improving and a rapid reduction in
mortality. At first, the mortality was around 88
per cent. Today the mortality in the hands of
skillful man, has been reduced in some large series,
as low as 5 per cent. In the hands of the casual
operator, the mortality is still very high, from 30
per cent up.

About one-third of all malignant tumors are gas-
tric cancers and surgery, we must remember, so
far is the only means of effecting a cure. We
know that these gastric cancer cases, if they get
no relief, will only live three or four months after
they enter the hospital, the average patients living
about three months after hospitalization, provided
no gastrectomy is done. The keynote to the suc-
cess is team work, special training in this type of
work, early operation and good postoperative and
preoperative care, with early diagnosis. The re-
sectability is about one case in three. Roughly,
in gastrectomies in skillful hands, one case in
every three survives for three years, one in four
for four years and one in five for ten years. When
the cancer is confined to the stomach at the time
of the operation, one in every two patients ob-
tains a five year cure.

Pack and Livingston stress that no single method
is suitable for every case of cancer, due to the
situation of the lesions. The operator should be
familiar with several types of gastrectomy. One
of the secrets of success is the approximation of
the soft parts without tension and the use of more
absorbable interrupted sutures in the peritoneal
layer.

As regards total gastrectomy, the mortality
is still rather high and the long term cure at pres-
ent is not there, but total gastrectomy is a feasible
operation and the mortality is rapidly being low-
ered. Some people will live three to four years af-
ter operation. This operation is rather difficult
technically, because the stomach, when a total gas-
trectomy is done, is more or less unapproachable,
with a tendency of the contractible esophagus to
pull away from the anastomosis. Some prefer to
approach through the thorax; others through the
abdomen. At times, it is almost mandatory that
we go through the thorax. We are very much in-
terested in this technic and at present are de-
voting a good deal of study to it. Possibly a
gastrectomy through the thorax and abdomen com-
bined may be best.

All in all, the technic of total gastrectomy must
be very much improved yet to make it a practical
operative procedure.

Dr. F. F. Boyce (in closing) : The best figures
on carcinoma of the stomach are from the Mayo
Clinic, where the operability is now well over 60
per cent, the resectability over 30 per cent, and

the mortality well under 10 per cent. The figures
from Charity Hospital naturally do not approach
any of these levels, and such improvement in re-
sectability as we have achieved has been accom-
plished by a wide extension of indications, which
I think is as it should be. These patients have
no other chance of salvation.

The most encouraging thing about the situation
at the New Orleans Charity Hospital is the de-
crease in the mortality of resection at the Hospital
for the last two years. It has fallen from more
than 50 per cent to about 27 per cent. In other
words, while our percentage of resectability, when
figured on the basis of all patients with carcinoma
of the stomach who enter the hospital, is still de-
pressingly small, we have halved the mortality of
resection in the last two years, and there is every
reason to hope that in the next two years it can
be still further reduced.

0

CLINICO - PATHOLOGICAL
CONFERENCE
CHARITY HOSPITAL
New Orleans

CASE HISTORY

J. B., a colored female, aged three and a half
months, was admitted August 16, 1943> and dis-
charged December 22, 1943; readmitted January
1, 1944 and died February 29, 1944.

C. C.-' Loss of appetite, vomiting, cough, and
fever, for two weeks.

P. I.-' The infant was born after a normal preg-
nancy and delivery, weighing six pounds, eight
ounces. She was breast fed for three months and
then placed on an evaporated milk formula. Cod
liver oil was first offered at two months. At two
weeks of age, intermittent attacks of diarrhea with
“green shiny stools” appeared. Weight gain and
appetite had been poor for at least two months.

P. E.: Temperature 104°, pulse 116, respiration
50, weight six pounds. The patient was a small,
emaciated, irritable female; skin showed marked
pallor and dilated superficial veins over the trunk.
There was apparent neck rigidity. The anterior
fontanelle was open, not bulging, and measured 3
cm. in diameter. She had an occasional cough and
a few fine moist rales over both lung bases. There
was a questionable enlargement of the heart to the
left, a definite mid-precordial systolic thrill, and a
definite, harsh systolic murmur over the base. Her
liver was palpable 2 cm. below the costal margin.

Laboratory: Hemoglobin 8 gm. per cent, red

blood cells 4 million, white blood cells 8,500 with
32 jier cent neutrophils, 65 per cent lymphocytes,
3 per cent monocytes. Urinalysis, Mantoux (0.1
and 1.0 mg.), Kline and Kolmer were negative.
Spinal fluid: clear and colorless, pressure of 250
mm., less than 10 cells, Pandy negative, chloride
752 mg. per cent. Blood and stool cultures were
repeatedly negative.

228

Clinico-Pathological Conference

EPA of chest on August 16, 1943, showed a
normal heart but a feathery pulmonary infiltra-
tion and depressed diaphragms.

Electrocardiogram within normal limits for pa-
tient’s age; QRS complexes diphasic in all leads.
Rate 160, PR interval 0.10, QRS 0.05.

Gastrointestinal series and barium enema dis-
closed essentially normal bowel except for some
“puddling” and adherences to the mucosal sur-
faces in the small bowel, some loss of haustral
markings in the large bowel.

X-rays of long bones revealed osteoporosis and
narrowed shafts.

Course: During the first ten days a course of
sulfadiazine was given, which apparently returned
her temperature to normal in three days. She now
weighed five pounds. Thereafter during Septem-
ber, her temperature remained within normal lim-
its. During October and November, however, there
were occasional elevations with some wide swings
from 97° to 103°. During febrile periods she be-
came irritable, restless, lost weight, and on one
occasion had a brief return of her cough, on an-
other a mild conjunctivitis. On October 24, 1943,
during a febrile period, a firm, tender swelling
of the right parotid appeared. Another course of
sulfadiazine was given without affecting the fever
or parotid mass. The parotid swelling gradually
became smaller and less tender but never disap-
peared. X-ray of this area showed a soft tissue
swelling without invasion of the underlying bone.
During December she remained essentially afebrile.
Chest x-ray in December disclosed apparent en-
largement of the heart to the left and extension
of the feathery lung infiltration to the periphery.

During her entire period of hospitalization, the
patient’s voluntary intake of food was always in-
adequate. Vitamins were supplemented in nearly
twice the usual requirements for her age. There
were bouts of foul-smelling liquid stools and oc-
casional periods of cough. She weighed eight
pounds at discharge.

She was readmitted in January, 1944, with a
history of draining ears of two weeks’ duration.
There was a purulent discharge from bilaterally
ruptured tympanic membranes, no rales could be
heard, the parotid mass measured 2x2 cm. and
was not attached to underlying structures. Other-
wise her physical condition was unchanged. Her
hemoglobin was 8.5 gm. per cent, red blood cells
3.8 million. Her white count and differential were
within normal limits. Urinalyses, Mantoux (0.1
mg.), Kline and Kolmer, spinal fluid, stool and
blood cultures were all negative. CO., c. p. of blood
was 40 vol. per cent, serum proteins 5.8 gm. per
cent. Encephalogram showed a mild dilation of
the third and lateral ventricles.

Sulfathiazole was given; sulfapyridine was sub-
stituted on February 4, 1944, and discontinued
on February 23, 1944. After the first readmission
day, she remained afebrile until February 1, 1944,

when she again began an irregular fever ranging
from 97° to 102.6°. Her ears continued to drain
pus. There were no respiratory symptoms. In
spite of high caloric, high vitamin, gavaged feed-
ings, she lost weight steadily until at death she
weighed six pounds, 10 ounces. During her last
week of life, she became increasingly listless. On
the day before death her eyes became glassy, she
cried when touched, sucking reflex disappeared,
marked diarrhea and vomiting reappeared.

Dr. Allan J. Hill: Diarrhea beginning at
the age of two weeks with marked malnu-
trition and pulmonary lesions suggests im-
mediately cystic fibrosis of the pancreas.
The x-ray appearance of the lungs in this
case conforms with that seen in this condi-
tion, but the stools were never typical.
Qualitative studies of stool fat and starch
content revealed no apparent abnormalities.
Duodenal enzyme studies were not done.

In any malnourished child who has lung
involvement associated with a history of
difficult feeding, lipoid pneumonia should
be considered. Oils, such .as cod liver oil
with a high fatty acid content, produce a
more acute and severe reaction. Other less
irritating lipids, such as milk butterfat,
may produce a less intense but more pro-
longed process. The common denominator
of all such cases is aspiration, which is rela-
tively common in premature infants and
in those who present feeding problems.
These chest x-rays are not typical of lipoid
pneumonia; one is more apt to see rounded
areas of increased density or definite con-
solidation rather than the increased bron-
chial markings shown in this picture. Al-
most all children with lipoid pneumonia re-
cover unless the disorder is complicated by
pulmonary infection.

If this child’s original infection at the
first admission were interstitial pneumonia,
the lingering wasting illness would be ex-
plained. The mortality of the initial acute
infection is high; those recovering are apt
to run a chronic course frequently termi-
nating in bronchiectasis. A preceding con-
tagious disease, such as measles or pertus-
sis, is not necessarily present.

A fungus infection of the lungs, while
possible in this case, would probably show
the agent in the sputum and is somewhat
more likely to produce nodular densities

Clinico-Pathological Conference

229

on x-ray. The wasting and diarrhea could
well fit into this picture if the fungus in-
fection also involved the gastrointestinal
tract.

Lymhadenopathy, parotid swelling, con-
junctivitis, and lung changes suggest
Boeck’s sarcoid. This disease is rare in
children; probably not more than 24 cases
in children have been reported in the liter-
ature, the youngest of which was three
months of age. Skin lesions usually are a
part of this syndrome, but they are not
necessarily present. Usually in Boeck’s
sarcoid there is much more enlargement of
the hilar nodes than was present here.

Pulmonary tuberculosis is another possi-
bility. The infant had at least four Man-
toux tests during her long period of hos-
pitilization. She had two three-day sputum
concentrations, but these were examined
only at the onset of her illness. All these
investigations for tuberculosis were nega-
tive. The x-rays were not characteristic
of tuberculosis, either of a primary infec-
tion or of a miliary spread. In addition,
most cases of miliary tuberculosis survive
less than six to eight weeks after the onset
of the disease.

The parotitis could well be non-specific,
as is often seen in cachectic states, rather
than a part of a definite disease syndrome.

The presence of a harsh basal systolic
murmur accompanied by a systolic thrill
would suggest a congenital cardiac defect.
In the absence of cyanosis, cardiac enlarge-
ment, and electrocardiographic changes, the
most likely diagnosis is a defect in the inter-
ventricular septum. Anemia alone might
explain such a murmur but not the thrill.

I believe the most probable diagnoses to
be considered are cystic fibrosis of the pan-
creas, interstitial pneumonia with chronic
pulmonary changes, and lipoid pneumonia.
The heart lesion is most likely an interven-
tricular septal defect.

Dr. Ralph V. Platou: I should like to
mention several additional diagnostic pos-
sibilities. At first glance this case seems
to justify the indefinite and hazardous term
“constitutional inferiority,” referring all
difficulties to a basic germ plasm defect.

The baby had, however, irrefutable symp-
toms and signs of congenital heart disease
(probably ventricular septal defect) along
with evidences of a number of other dis-
tinct organic distrubances. As a basis for
the most prominent and obvious feature of
marasmus (which this child exhibited to
the nth degree) we know that a chronic
systemic infection should be demonstrable
as the most frequent cause; certainly un-
qualified marasmus, cachexia, or athrepsia
alone is inadequate.

We expect the pathologists to demon-
strate cystic fibrosis of the pancreas with
secondary pulmonary changes. As you
know, this condition can be differentiated
from the general celiac syndrome during
life by demonstrating a deficiency of tryp-
sin in the duodenal contents ; we tried to
secure duodenal drainage but were unsuc-
cessful. Hypoproteinemia was demonstrat-
ed, and at various times we were impressed
by equivocal manifestations of multiple
avitaminoses, in spite of the fact that the
infant had been given a high caloric-high
vitamin diet. This leads us to believe that
there must have been specific or general
defects in absorption or utilization of the
various dietary essentials, most likely on
the basis of pancreatic insufficiency.

Malignancy was of course strongly sug-
gested by the cachectic appearance of this
baby throughout our period of observation.
We had felt quite confident that the parotid
tumor represented either a primary endo-
thelioma, hemangio-endothelioma or pos-
sibly an unusual metastatic lesion from an
undetermined primary lesion elsewhere.
The surgical consultants justifiably refused
either to remove or biopsy this parotid tu-
mor because of the extremely poor condi-
tion of the patient; we agreed with them
that it would be wiser to learn the nature
of this lesion from post mortem study, in-
asmuch as it appeared all too obvious that
no constructive operative work would be
possible during life.

It is certainly true that all the clinical
features we have observed in this case could
be explained by a diagnosis of Boeck’s sar-
coid. The fact, however, that this lesion has

230

Clinico-Pathological Conference

not been described in any patient so young
makes it seem very unlikely, and the only
reason we considered this possibility was
the fact that we could not prove our first
suspicion of tuberculosis by means of the
usual diagnostic criteria, namely, intracu-
taneous testing, roentgen-ray examination,
or repeated examination of sputum secured
by gastric lavage.

Dr. Roscoe Pullen: What about Hand-
Schiiller-Christian’s disease ?

Dr. Platou: The child never had any dem-
onstrable xanthomata and did not exhibit
diabetes insipidus.

Student: What about subacute bacterial
endocarditis?

Dr. Platou: It seems that there are
enough possibilities to consider already.
Subacute bacterial endocarditis is extreme-
ly unusual in infants. This child never
demonstrated the typical “spiking” fever,
had no embolic phenomena, and blood cul-
tures were repeatedly negative.

Dr. J. D. Russ: I did not see this patient
so what I say is based on what I have read
in the abstract. One diagnosis Dr. Hill
mentioned as a possibility was lipoid pneu-
monia. The diagnosis of lipoid pneumonia
is based on two bits of evidence — the his-
tory and x-ray findings. The history is not
compatible and there is some doubt about
the x-ray findings. The x-ray findings in
lipoid pneumonia should show more exten-
sive involvement of the right lung. I would
like to bring up two other diagnostic possi-
bilities, one, congenital heart disease, and
two, syphilis.

Dr. Ernest Stark: Anatomic Findings.
This child weighed only 8 pounds. It was
extremely undernourished. There was no
swelling of the parotid although this was
looked for with care.

Dr. Hill and Dr. Platou have both made
the correct anatomic diagnosis of the car-
diac lesion. There was a small interven-
tricular septal defect. The right ventricle
was large and dilated. The foramen ovale
was patent, but the opening was covered by
a flap of endocardium. The pulmonary
valves showed a further congenital deform-
ity. There were only two leaflets. These

were somewhere thickened along their free
margins. Microscopically, these valves
showed edema but there were no inflam-
matory changes. The bifurcation of the
pulmonary artery occurred just above the
level of the pulmonary valves.

An incidental finding was a small tumor
of the left adrenal medulla. On microscopic
examination this proved to be a neuroblas-
toma which has as yet not spread beyond
the confines of the gland. It is safe to say
that this tumor had nothing to do .with the
child’s illness or death.

The cause of death in this case was tuber-
culosis. This child had miliary tubercu-
losis. We have been unable to determine
when the first infection took place, but
there was evidence that the initial infection
involved the lung. The evidence for this
was an enlarged tracheobronchial lymph-
node showing extensive caseation and fibro-
sis. I am unable to demonstrate the pri-
mary focus in the lung itself because the
lungs showed numerous disseminated tuber-
culous nodules of varying size.

The liver showed many minute tubercles.
The spleen was likewise involved but here
the tuberculous lesions were of larger size
and many showed gross caseation.

There were no ulcerations in the intes-
tinal tract and the mesenteric lymph-nodes
were not remarkable. The pancreas showed
no abnormalities on either gross or micro-
scopic examination.

Another finding of interest was a tuber-
culous salpingitis on the right side. The
entire tube was swollen to about twice the
normal diameter and the entire wall showed
caseation and necrosis. The left Fallopian
tube was normal on gross examination but
microscopically, there were a few early tu-
bercules like the one reproduced in this
lantern slide.

Dr. Hill: I am embarrassed that I missed
the diagnosis in this case. However, on
the basis of the findings I believe I would
make the same mistake again. Repeatedly
negative Mantoux tests over this long a
period of time and two negative gastric
washings discouraged a serious considera-
tion of tuberculosis. However, a persis-

Clinico-Pathological Conference

231

tently negative Mantoux could consistently
occur in the presence of marked emaciation.
Could there be caseation of the degree dem-
onstrated in this case in the lesions of
Boeck’s sarcoid?

Dr. Stark: The clinical findings could be
explained by Boeck’s sarcoid but the patho-
logical findings could not be so explained.
Caseation and necrosis never assume such
marked proportions in sarcoid lesions. We
have looked for acid-fast bacilli and have
found a few organisms in some of the
lesions.

Dr. Julius Lane Wilson: I would like to
ask something about this case. What is the
incidence of primary focus six months be-
fore death? What happened? Did this
child live for six months with generalized
tuberculosis, or did this appear recently?
I can not answer these questions, and I
think they are important.

Dr. Stark: I can say this — all these le-
sions showed either marked caseation or
else simply small tubercules composed en-
tirely of epitheloid cells and lymphocytes
without much caseation. None showed fi-
brosis to the extent where it could be said
that the lesion was healed, or healing. No
calcification was present. This means that
these were fairly recent lesions, but exactly
how old I could not estimate. They could
certainly have occurred in a few weeks.

Dr. Wilson: It seems incredible to me
that the x-ray did not show miliary tuber-
culosis. It is most probable that the pa-
tient was infected before she came into the
hospital; she had a primary lesion, then
salpingitis, and from this, hematogenous
dissemination leading to the final stages of
miliary tuberculosis. It is incredible that
she had nine months of miliary tubercu-
losis.

Dr. Stark: I agree with you that it seems
a long time to live with miliary tubercu-
losis.

Dr. Wilson: I think we have this point
to consider. You .cannot exclude a diag-
nosis of tuberculosis because of negative
tests.

Dr. Stark: Of course we are not sur-
prised because an infection of this type
often gives negative tests.

Dr. Platon: We are certainly willing to
accept the lesson this case teaches — that
there is no test for the presence of tuber-
culosis which is absolutely infallible, accur-
ate as these are in the great majority of
cases. I feel quite confident that given this
same situation, we would again consider a
diagnosis of tuberculosis to be quite ade-
quately excluded by the procedures previ-
ously mentioned. I should like to ask Dr.
Wilson his opinion concerning the danger
and infectious nature of such an unrecog-
nized case of miliary tuberculosis in the
hospital.

Dr. Wilson: A student is less apt to con-
tract tuberculosis working in a tuberculosis
sanatorium than he is on the medical and
surgical wards where unrecognized tuber-
culosis is apt to be present. The students
should be allowed training with infectious
diseases, but he should protect himself to
the greatest possible extent. I would re-
gard the parents, friends, and family con-
tacts of such a patient q great danger to
the other children on the wards. The child
with miliary tuberculosis alone could con-
stitute no possible danger to the personnel
or other patients. In these cases, the le-
sions are confined to the perivascular tis-
sues and do not communicate with the air
passages.

Clinician’s Diagnoses :

1. Cystic fibrosis of pancreas.

Chronic pulmonary fibrosis and
bronchitis.

2. Congenital heart disease.

Cyanose tardive group.

Interventricular septal defect.

Pathologist’s Diagnoses:

1. Miliary tuberculosis.

2. Congenital heart disease.

Interventricular septal defect.

Low bifurcation of pulmonary ar-
tery.

Bicuspid pulmonary valve.

3. Neuroblastoma of adrenal.

232

Editorials

NEW ORLEANS

Medical and Surgical Journal

Established. 18UU

Published by the Louisiana State Medical Society
under the jurisdiction of the following named
Journal Committee:

Val H. Fuchs, M. D., Ex officio
For two years: G. C. Anderson, M. D., Chairman
Leon J. Menville, M. D.

For one year: J. K. Howies, M. D., Vice-Chairman
For three years: C. Grenes Cole, M. D., Secretary
E. L. Leckert, M. D.

EDITORIAL STAFF

John H. Musser, M. D Editor-in-Chief

Willard R. Wirth, M. D Editor

Daniel J. Murphy, M. D. Associate Editor

COLLABORATORS— COUNCILORS
Edwin L. Zander, M. D.

J. T. O’Ferrall, M. D.

Guy R. Jones, M. D.

T. B. Tooke, Sr., M. D.

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W. E. Barker, Jr., M. D.

C. A. Martin, M. D.

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1430 Tulane Avenue

SUBSCRIPTION TERMS: $3.00 per year in ad-
vance, postage paid, for the United States; $3.50
per year for all foreign countries belonging to the
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not later than the eighteenth of the month preced-
ing publication. Orders for reprints must be sent
in duplicate when returning galley proof.

Manuscripts should be addressed to the Editor,
1130 Tulane Avenue, New Orleans, La.

The Journal does not hold itself responsible for
statements made by any contributor.

DEMEROL

The new synthetic analgesic, demerol,
was synthesized in 1939 by Eisleb and
Schaumann. Recently reports on its phar-
macology and clinical use have appeared in
this country, and its application has in-
creased. In two articles by Yonkman, Noth
and Hecht* the results of pharmacologic
studies and clinical observations are re-
ported.

The pharmocologic studies in animals
and man cause the authors to conclude that
demerol is a safe drug readily absorbed
after oral, subcutaneous or intramuscular

use, with a weak atropine-like action and
a moderately strong papaverine-like effect.

It produces an analgesic, spasmolytic and
sedative effect. In humans it does not pro-
duce an intestinal stimulating action. Its
atropine-like effect produces mydriasis,
suppression of saliva, and insulation of the
heart, bronchi and intestine against vagal
stimulation. Its papaverine-like spasmo-
lytic action directly relaxes the bronchi, in-
testine, uterus and blood vessels. Like mor-
phine it produces analgesia, sedation, eu-
phoria and sometimes morphine-like side-
effects.

Since 1939, many clinical reports on the
use of the drug have been published in
South America and European literature,
covering observations on several thousand
cases. Since 1943, a few reports have ap-
peared in this country. These authors com-
pare their clinical results in 146 patients,
and compare them with those previously re-
ported. The usual dose for adults was 100
milligrams; the dose ranged from 50 to 200
milligrams. The dosage for children is
stated to range from 10 to 75 milligrams.
It has been administered orally, intramus-
cularly, subcutaneously or by rectal suppos-
itories occasionally. When used intraven-
ously it should be diluted and given slowly.
In their cases the drug was given usually
in 100 milligram doses, orally or intra-
muscularly, from one to eight times daily.
The intramuscular route is more prompt
than the oral route, and is preferred over
the subcutaneous administration because of
irritation.

In 64.2 per cent of the cases with severe
pain, complete relief occurred in from five
to 20 minutes when given by needle, and
from 20 to 30 minutes when given by
mouth. Its duration varied from one to six
hours, the average being three or four
hours. Partial relief occurred in 23.6 per
cent, and no relief in 12.2 per cent.

The analgesic potency in 100 milligram
dose was greater than one grain of codein
and less than one-quarter to one-sixth of
morphine. Three out of four patients with
status asthmaticus were benefited by the
drug. Side effect occurred in 27.4 per cent.
The drug may have properties causing ad-

Editorials

233

diction, but these are said to be less marked
than some of the opiates, morphine and its
derivatives. It was used in a variety of
conditions and the authors feel that demerol
may replace these drugs in many condi-
tions.

A further report is presented by Batter-
manf who analyzes the results in over 4,000
patients treated at Bellevue Hospital since
1941. Be believes its greatest usefulness is
in the postoperative relief of pain because
its failure to produce deep narcosis, respi-
ratory depression, urinary retention, or
alter the cough reflex makes it more desir-
able than morphine. It is equally effective
as morphine in controlling pain due to
smooth muscle spasm. It was used in pleu-
ritic and arthritic pain, in chronic chest
conditions, as an analgesic in obstetrics, in
pruritus, acute or chronic asthma, myocar-
dial infarction and as a pre-anesthetic seda-
tive. It is regarded as a relatively safe
drug with less liability to habit formation
than morphine.

*Yonkman, Frederick F., Noth, Paul H., and
Hecht, Hans H. : Demerol, a new synthetic anal-
getic, spasmolytic and sedative agent. I Pharma-
cological observations, II Clinical observations, Am.
Int. Med., 21:7, 1944.

fBatterman, Robert C.: Demerol: A new syn-
thetic analgesic: Its indications as a substitute for
morphine, Conn. State M. J., 8:13, 1944.

O

KIDNEY CALCULI

This important urological problem is dis-
cussed with relation to the formation, rec-
ognition and treatment of kidney calculi by
Randall.* He discusses the five general
theories of stone formation, avitaminosis A,
hyperparathyroidism, infection, colloidal
imbalance and stasis. None of these solve
the problem of etiology completely but must
be considered along with contributing fac-
tors, and that stone is only a symptom of a
pre-existent pathologic lesion. The author
states that in his opinion only two essential
conditions are necessary for the formation
of stone; “first, a primary tissue damage,
and second, a permanent or transient and
oft repeated, hyperexecretory state.”

As to treatment, pyelolithotomy is briefly

discussed and then ureterolithotomy and
instrumental manipulations for ureteral
calculi. The author feels that the use of
spinal anesthesia in these last two proce-
dures is most important because of the per-
fect relaxation produced.

The prevention of kidney calculi will be
greatly aided by a knowledge of the chem-
ical character of the stone. The uric acid
stones demand a careful metabolic study
and an alkalinizing drug to keep the p H of
the urine at about 6.0. The oxalate stone
suggests dietary management and moderate
alkalinization. In both cases all focal in-
fections'should be removed and at least
2,000 cc. water taken daily. The calcium
phosphate stone should be assured a well-
balanced diet and tested for hyperparathy-
roidism. He states that after all the “tak-
ing of larger quantities of water daily is
perhaps the surest answer to our question
of prevention.”

*Randall, Alexander: Recent advance in knowl-
edge relating to the formation, recognition and
treatment of kidney calculi, Bull. N. Y. Acad.
Med., 20:433, 1944.

O

ARTERIOSCLEROSIS

The etiology of this very important path-
ological process has been under constant
investigation. Nothing need be said to em-
phasize our lack of definite information
that would assist in the prevention of a
condition which has so much to do with the
problems of advancing age. Many factors
have been enumerated and one phase of the
subject which has attracted considerable
attention is the relationship between hyper-
cholesterolemia and atherosclerosis. Some
investigators have shown experimentally a
suggested relationship.

Studying this problem clinically Shaffer*
concluded that an increased cholesterol in-
take did not in his observations increase
the incidence of atherosclerosis, at least as
far as the coronaries were concerned. One
hundred patients on a high cholesterol diet
were compared with 500 patients eating
normally and there was little or no differ-
ence in the two groups.

The patients were old duodenal ulcer

234

Orcja nization Section

cases on a milk and cream diet. Coronary
arteriosclerosis was considered present
when there was coronary occlusion with
myocardial infarction, angina pectoris and
certain conduction disturbances. In the
group three per cent had myocardial in-
farction, three per cent had angina pectoris
and three had evidence of arteriosclerotic
heart disease. In the control group in the
same age bracket, 45-65 years, same sex
ratio, 19:1 males to females, there was an
identical three per cent with coronary oc-

clusion with myocardial infarction, 2.5 per
cent with angina pectoris and 5 per cent
with arteriosclerotic heart disease.

The author felt that these observations
justify the conclusion that unless there is
an associated endocrine imbalance, there is
no clinical evidence of causative relation-
ship between hypercholesterolemia and ath-
erosclerosis.

*Shaffer, Carl F.: The nutritional role of choles-
terol in human coronary arteriosclerosis, Ann. Int.
Med., 20:948, 1943.

ORGANIZATION SECTION

The Executive Committee dedicates this page to the members of the Louisiana
State Medical Society, feeling that a proper discussion of salient issues will contri-
bute to the understanding and fortification of our Society.

An informed profession should be a wise one.

INITIATION OF A PHYSICAL FITNESS
PROGRAM

In July, 1944, at a hearing of the Sub-
committee of the Senate on Health and
Wartime Education, Major General Lewis
B. Hershey, Director of the Selective Serv-
ice System, is quoted to have said:

“If the citizenry of the future is to be
prepared to insure peace by being able to
make war, and if the citizens of the State
are to be physically able to carry out their
other duties efficiently and effectively, then
there must be definite and positive meas-
ures taken to insure the development, the
training and the conditioning of our youth
to the end that they will be physically
strong and emotionally stable. If they are
not physically strong and emotionally sta-
ble, they will not be able to use the knowl-
edge which has been imparted to them in
our schools. It is idle to talk of a democ-
racy, in which each citizen has equal op-
portunities with every other citizen and
equal responsibilities with every other citi-
zen, unless these citizens each and every
one are able when the responsibility comes
to carry their part. There is no justice,
there is no fairness, there is no democracy
when 16,000,000 of our citizens must carry
the load of 22,000,000 of our citizenry ; and
unless and until we are able to take such
measures which will insure that the maxi-

mum of our citizens are able to bear arms,
and able to accept all of the responsibilities
of citizens, we can have democracy only in
name.”

Colonel Leonard G. Rowntree, Chief of
the Medical Division, National Headquar-
ters, Selective Service System, after pre-
senting detailed analysis of the causes for
rejections, advocated a program for making
the nation biologically fit for whatever is
its mission in the postwar world. Quota-
tions from this presentation are as follows:

“The Government of the United States —
Federal, state, or local — has a rightful con-
cern in the poor state of health evidenced
in Selective Service findings. The rejectee
in many instances is the victim of our mod-
ern civilization. The failure has been that
of Federal, state, and community authori-
ties of the parents, of education, the church,
and of medicine, dentistry and public
health, and to some extent of the individu-
al concerned. The remedy calls for con-
certed action on the part of all these groups
responsible for the situation which was
found to exist.

“The Sociological and economic factors
are indissolubly bound up with the avail-
ability and utilization of good medical care.
We are not the vigorous people that we
thought we were. The people must be edu-
cated to accept the fact that we have a high

Organization Section

235

percentage of defects, deficiencies, disabili-
ties, disorders, and diseases. We must be
educated to demand medical care in propor-
tion to the demonstrated need of that
care.”

On September 18, 19, and 20 another se-
ries of hearings were conducted in which
the President-elect of the American Medi-
cal Association, Dr. Roger I. Lee, appeared.
He offered some constructive suggestions
and defended the medical profession in
their handling of selectees and also the
wonderful record made by the profession
in maintaining this country on such a low
mortality and morbidity rate. This has
been accomplished while some 55,000 of our
doctors have been removed from civilian
service in the Armed Forces. He specifi-
cally urged that owing to the great number
of rejectees 4,000,000 of the total number
examined or 35 per cent, one-sixth of whom
were remedial, that the medical profession
had a grave and serious problem to con-
sider. That the medical profession was
conscious of its responsibilities and that
ordinary medical care of the people of the
United States is not enough. It must be
good medical care. Various other distin-
guished members of the profession ap-
peared before the committee to give their
impressions and constructive thoughts on
this vital problem. These hearings wTere
conducted under the authority of Senate
Resolution number 74 which authorizes the
subcommittee to make a full and complete
study and investigation regarding the dis-
tribution and utilization of medical per-
sonnel, facilities, and related health serv-
ice. It was brought out by the testimony
of Dr. Thomas Parran, Surgeon General
of the United States Public Health Service,
that the Social Security Agency and the
United States Public Health Service had
some very definite plans for the support
and relief of this lack of physical fitness
as evidenced in the above rejectees. As a
result of all these hearings, a committee of
one hundred was appointed by the Presi-
dent of the United States comprising some
of the most capable physicians to draw up
some definite plans for action by the vari-

ous states. The United States Public
Health Service, in cooperation with the
American Medical Association, appointed a
National Committee for this purpose.
Colonel Leonard G. Rowntree, Chief of the
Medical Division, National Headquarters,
Selective Service System, is Chairman of
this Committee. Some appeal has been
made evidently to the Governors of various
states for the purpose of calling a confer-
ence to consider remedial methods to im-
prove the physical fitness of the youth of
this country. Accordingly, on October 19
there was held a conference in Raton Rouge
of all the leading organizations who would
obviously be concerned in any definite phy-
sical fitness program. This conference
was arranged by Jess W. Hair, Chairman,
Committee on Recreation and Physical Fit-
ness, Louisiana Civilian Defense Council,
under auspices of the Department of Health
of Louisiana, at the request of Governor
James Davis. The Louisiana State Medi-
cal Society was represented at this confer-
ence. They also have a representative on
the Executive Committee. It was agreed at
the Executive Committee meeting that be-
fore any definite plans for physical fitness
were developed and approved that the fol-
lowing principles be adopted : First, a com-
prehensive physical program plan from the
cradle to the grave; second, a survey to be
made of the state in regard to facilities as
presently available and the future need in
any plan developed for physical fitness in
the state ; third, each member of the Execu-
tive Committee was to write to the chair-
man his ideas for a definite physical fit-
ness plan.

The above facts are presented for the
purpose of informing our 'profession of the
thoughts and attitudes of some of our na-
tional leaders in the medical profession, and
it is well to visualize just what we are faced
with in our respective state. L-nquestion-
ably, the medical profession is most de-
sirous of taking its place in some construc-
tive plan to obviate the high rate of re-
jectees and evidence of lack of physical fit-
ness. Furthermore, it is very plain to all
thinkers that a Utopia in this regard is not

236

Orleans Parish Medical Society

possible, but by properly coordinating and
correlating the various forces needed and
maintained on a state level we might en-
deavor to develop a suitable program to
take care of this serious situation. The
seriousness of this is very evident, and un-
less we organize and accomplish the proper
spirit and cooperation on a state level the
Federal Government is prepared to come
in and supervise or take over such action
as may be deemed advisable. The medical
profession of this state should therefore
give its earnest thought and consideration
and instruct its representatives in the med-
ical profession the course and manner to
be pursued.

It must be very astounding to all those
who had the occasion to know that on Oc-
tober 4 the American Public Health Asso-
ciation adopted a report favoring in effect
a Federal plan of compulsory health in-
surance. This was done without due con-
sultation with medical and dental leaders
of the nation. These organizations had pre-
viously made such a proposal to the Ameri-
can Public Health Association. All those
interested in this report will find a copy
of same in the October 14 issue of the

American Medical Association Journal on
page 441. From the above it would not
seem that we have yet removed the dangers
of the Wagner-Murray-Dingell Bill or its
implications as contained in the amendment
to the Social Security Act, Senate Bill 1161.
It is very distressing to know that we have
such dissention in our midst. The person-
nel of the American Public Health Associa-
tion is about ninety-five per cent physi-
cians. However, the majority of these are
primarily interested in preventive and
public health work, and do not see eye to
eye with the regular practitioners of medi-
cine in civilian life.

There will be a meeting of our Executive
Committee on November 11 in New Or-
leans. At this time due consideration will
be given to the selection of dates, location,
and character of meeting to be held for
the 1945 session of the Louisiana State
Medical Society. You are urgently request-
ed to make your desire and wishes known
to your officers and councilors in your re-
spective districts in order that they may
bring to this meeting the attitude of the
profession in this regard, or on any other
problem.

TRANSACTIONS OF ORLEANS PARISH MEDICAL SOCIETY

Nov.

1

CALENDAR OF MEETINGS
Mercy Hospital Staff, 8 p. in.

Nov.

Nov.

22

23

French Hospital Staff, 8 p. m.
Clinico-pathologic Conference, Touro

In-

Nov.

Nov.

2

6

Clinico-pathologic Conference, Touro In-
firmary, 11:15 a. m.

Chaille Memorial Oration, Hutchinson

Nov.

24

firmary, 11:15 a. m.

DePaul Sanitarium Staff, 8 p. m.
New Orleans Hospital Dispensary

for

Nov.

7

Memorial Auditorium, 8 p. m.

Eye, Ear, Nose and Throat Hospital

Nov.

28

Women and Children Staff, 8 p. m.
Baptist Hospital Staff, 8 p. m.

Nov.

8

Staff, 8 p. m.

Women’s Auxiliary, Orleans Parish Med-

HOSPITAL NEWS

ical Society, Orleans Club, 3 p. m.

Clinico-pathologic Conference, Marine
Hospital, 7:30 p. m.

Touro Infirmary Staff, 8 p. m.

Nov. 13 Scientific Meeting, Orleans Parish Medi-
cal Society, 8 p. m.

Nov. 15 Charity Hospital Surgical Staff, 8 p. m.

Nov. 16 Clinico-pathologic Conference, Touro In-
firmary, 11:15 a. m.

Nov. 17 I. C. R. R. Hospital, 12:30 p. m.

Nov. 20 Hotel Dieu Staff, 8 p. m.

Nov. 21 Charity Hospital Medical Staff, 8 p. m.

At the first fall meeting of the Staff of Mercy
Hospital held October 4, Dr. Edgar Hull spoke on
carcinoma of the lung and Dr. F. F. Boyce dis-
cussed the surgical aspects of this condition. A
motion picture on modern nutrition' was shown.
The X-ray Department of the hospital has an-
nounced that the present equipment will soon be
replaced by a new and far superior radiographic
unit. A new Young urologic X-ray table has been
secured for the cystoscopic room, and a new in-
ductotherm has been ordered to replace the pres-
ent diathermv machine. Dr. Louis A. Monte has

Louisiana State Medical Society Neivs

237

teen elected Chairman of the Mercy Hospital
Nursing School Faculty; Dr. Charles Midlo, Vice-
Chairman; and Drs. E. L. Zander, and Geo. Hauser
members of the Board. Fourteen nurses received
diplomas at commencement exercises held, Septem-
ber 1.

NEWS ITEMS

At the Seventh District Medical Society meeting
at Jennings September 28 Dr. Donovan C. Browne
spoke on the differential diagnosis of diarrhea and
Dr. J. D. Rives on carcinoma of the rectum.

Dr. Alton Ochsner recently addressed the Fulton
County Medical Society in Atlanta, the Lawson
General Hospital, and the Sheffield Cancer Clinic.

Dr. Emil E. Palik served as one of the quiz-mas-
ters for the examination in pathology which was
part of the examination conducted by the Ameri-
can Board of Orthopedics at Tulane University
School of Medicine, September 29-30.

Dr. Bernard B. Weinstein has been appointed to
the Research Co-ordinating Committee of the

American Society for the Study of Sterility.

Dr. Guy Caldwell has been elected Vice-Presi-
dent of the Orleans Parish Chapter of the Nation-
al Foundation for Infantile Paralysis.

At the ninth annual assembly and convocation
of the United States Chapter of the International
College of Surgeons held in Philadelphia October
5, Drs. J. C. Menendez, M. Lyon Stadiem and C.
Walter Mattingly were admitted to fellowship and
Dr. Eugene H. Claverie was admitted to member-
ship.

Dr. Dean H. Echols attended the meeting of the
American Academy of Neurosurgery at White
Sulphur Springs, September 14-16.

Dr. T. J. Dimitry has been informed of his elec-
tion to active membership in the Association for
Research in Ophthalmology. The objects of the As-
sociation are “to encourage, promote, foster and as-
sist investigations and research in ophthalmology.”
Dr. Daniel J. Murphy, Secretary.

-0

LOUISIANA STATE MEDICAL SOCIETY NEWS

CALENDAR

Society

East Baton Rouge

Morehouse

Orleans

Ouachita

Rapides

Sabine

Second District

Shreveport

Vernon

PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS

Date

Second Wednesday of every month
Second Tuesday of every month
Second Monday of every month
First Thursday of every month
First Monday of every month
First Wednesday of every month
Third Thursday of every month
First Tuesday of every month
First Thursday of every month

Place

Baton Rouge
Bastrop
New Orleans
Monroe
Alexandria

Shreveport

TULANE GRADUATION

The second class of students to graduate from
Tulane Medical School in 1944 were given their
diplomas Saturday, October 14. Dr. Jacob C.
Geiger delivered the Graduation Address and was
given an honorary degree by the University.

On Friday, October 13, the Ivy Day Program
was held, at which time Dr. E. C. Faust gave the
Ivy Day Address. Charles D. Knight presented
the class gift to Dr. H. W. Kostmayer. The fol-
lowing prizes were awarded: Isadore Dyer Medal
to John W. Deming; Querens-Rives-Shore Award
to Ross F. Bass; Walter Reed Memorial Medal to
Emile A. Bertucci, Jr.; Jacob C. Geiger Medal to
Arnold H. Baum; Sidney K. Simon Prize to Charles
D. Knight; award by the Professor of Medicine to
James C. Prose and John W. Bassett, with honor-
able mention to Juan Arosemena and Pascal G.

Batson, Jr. Announcement was made of Alpha
Omega Alpha membership from the Junior class
to Thomas G. Baffes.

o

SYMPOSIUM ON THE HEART AND
CIRCULATION

A most successful three-day course on the car-
diovascular system was held at Louisiana State
University Medical School on October 25-27. Par-
ticipating in the program were various members
of the Department of Medicine of Louisiana State
University as well as other local men. Visiting
lecturers included Dr. Maurice Visscher of the
University of Minnesota School of Medicine; Dr.
Isaac Starr of the University of Pennsylvania
School of Medicine and Dr. Frank N. Wilson of
the University of Michigan School of Medicine.

238

Louisiana State Medical Society News

SOUTHERN MEDICAL ASSOCIATION

The 1944 meeting of the Southern Medical Asso-
ciation will be held in St. Louis beginning the week
of November 13. The program for the first day
and a half will consist of clinical sessions. Begin-
ning Tuesday afternoon, November 14, and con-
tinuing through Thursday, programs of twenty
sections of the Association will be presented.

There will be conjoint meetings with the South-
ern Branch of the American College of Chest
Physicians, of the American Public Health Asso-
ciation, and the American Society of Tropical
Medicine.

At the general public session Dr. Herman L.
Kretschmer, President of the American Medical
Association, will give the annual address. There
will also be an address by Major Albert J. Stowe,
who will speak as a personal representative of
Major General Clayton Bissell, Assistant Chief of
Staff, G-2 (Military Intelligence). On Wednesday
evening there will be another general public ses-
sion devoted to “Medicine in the War” at which
occasion there will be motion pictures and speakers
from top ranking officers of the Army and Navy.

Thei'e will be no official social activities at any
time.

ALPHA OMEGA ALPHA

The Stars and Bars chapter of Alpha Omega
Alpha honorary medical fraternity initiated, on
the evening of Wednesday, October 4, 1944, the
following undergraduate Senior students of Tu-
lane: John W. Deming, William J. Langlois, Jr.,
Charles Knight, Emile Bertucci, Jr., Philip Berg-
man, John W. Bassett, Herbert M. Perr, Henry R.
Hyslop, Fernand Dastugue, Jr., Alan Leonard,
Nadene Denison, and John P. Fischer.

Dr. H. W. Kostmayer, Dean of the Tulane Med-
ical School, was made an honorary member.

The newly created Alpha Omega Alpha Lecture-
ship was delivered by Dr. Anton J. Carlson, Pro-
fessor Emeritus of Physiology at the University
of Chicago School of Medicine. The title of Dr.
Carlson’s address was “Some Unknowns in the
Physiology of Aging.”

DR. ROY CARL YOUNG HONORED

At the meeting of the National Association of
Private Psychiatric Hospitals held at the Bellevue-
Stratford Hotel, Philadelphia, Pennsylvania, on
May 14, 1944, Doctor Roy Carl Young of Cov-
ington, Louisiana, of the Fenwick Sanitarium, was
elected to the Board of Trustees of this organiza-
tion for a three-year period.

Doctor Young was also honored on being ap-
pointed on the membership committee and Chair-
man for the Local Division South.

NEWS ITEMS

Dr. John R. Schenken, professor and Director
of the Department of Pathology and Bacteriology,
Louisiana State University School of Medicine, ad-
dressed the Second District Medical Society of
Florida at Quincy, Florida, on October 19. He
spoke on the relationship of hormones to cancer
and on the pathology of amebiasis.

The following communication has been received
dated Quebec, August 25, 1944 :

“We regret very much to inform you that for
leasons beyond our control, the Congress of the
Association of French Speaking Physicians of
North America which was to have taken place on
September 5-7 has been postponed to a later date.
We hope to reorganize later and count on your
presence at that time. If you have already paid
your dues, it will serve for the next Congress.
The membership card is the official receipt.”

The Annual Conference of State Secretaries and
Editors will be held at the office of the American
Medical Association in Chicago, November 17-18.

It is with regret that we learn of the departure
from the city of Mr. Donald H. Higgins, manag-
ing editor of The New Orleans Item. Mr. Higgins
has been much interested in civic affairs in the
city and particularly with medico-social activities.
He has been one of the active members of the
Board of the Tuberculosis Association of New Or-
leans and has been a vigorous and active worker
in the Social Hygiene Association of the city.

Notice has been received of the opening of the
following district office of the Division of Nurse
Education, U. S. Public Health Service:

District 4, 1307 Pere Marquette Building, 150
Baronne Street, New Orleans 13, Louisiana: Miss
Elsie T. Berdan, Nurse Education Consultant in
charge. Territory includes: Alabama, Florida,

Georgia, Louisiana, Mississippi, New Mexico, South
Carolina, Texas and Tennessee.

The next written examination and review of
case histories (Part I) of the American Board of
Obstetrics and Gynecology for all candidates will
be held in various cities of the United States and
Canada on Saturday, February 3, 1945, at 2:00
p. m. Candidates who successfully complete the
Part I examination proceed automatically to the
Part II examination held later in the year. All
applications must be in the office of the Secretary
by November 15, 1944.

o

SOUTHERN BAPTIST HOSPITAL
The regular clinical staff meeting was held on
the evening of September 26 at 8:00 p. m. in the
auditorium of the hospital. The program consisted
of a presentation by Dr. Julius W. Davenport, Jr.,
entitled “The Rh Factors.” Dr. Joe Wells then
presented the death report of the previous month.

Louisiana State Medical Society News

239

MEDICAL OFFICERS NEEDED

The Civil Service Commission has announced a
new examination for Rotating Interneship and
Psychiatric Resident positions at St. Elizabeth’s
Hospital, the Federal institution for the treatment
of mental disorders, in Washington, D. C. The
positions pay $2,433 a year, including overtime
pay. Further details may be obtained in Journal
office.

o

AMERICAN HOSPITAL ASSOCIATION

Dr. A. C. Bachmeyer, director of the University
of Chicago Clinics, was appointed to conduct a
two-year survey of America’s hospital system at
the initial meeting of the Commission on Hospital
Care in Philadelphia August 1. The Commission
was organized on the request of members of the
American Hospital Association for an independent,
unbiased study to serve as a basis for plans for
future hospital facilities and the extension of those
already in service.

In his capacity as permanent director of study,
Dr. Bachmeyer will make a survey of hospital fa-
cilities in three states — California, Michigan, and
one in the South — to determine the health needs
of every segment of the population, and to investi-
gate the potentialities for an even wider distribu-
tion of hospital service.

On the basis of these studies, a nation-wide plan
looking toward greater co-ordination among hos-
pitals will be developed, aimed at extending hos-
pital care of the sick and injured equally to all — -
the farmer, the laborer, the urban dweller, and
those groups requiring specialized attention for
mental and incurable diseases.

Dr. Thomas S. Gates, president of the University
of Pennsylvania, is chairman of the Commission,
which has been financed by a fund of $105,000 con-
tributed by the Kellogg Foundation, the Commmon-
wealth Fund of New York, and the National Foun-
dation for Infantile Paralysis.

■ o —

INFECTIOUS DISEASES IN LOUISIANA

The Louisiana State Board of Health reported
that for the week ending September 16 there were
reported 39 cases of pulmonary tuberculosis, 29
of measles, and 18 of endemic typhus fever. There
were no other diseases reported in numbers greater
than 10. Of the unusual diseases there were listed
two cases of poliomyelitis, one from Bossier and
one from Grant Parish, and five cases of typhoid
fever scattered over the state, no one parish hav-
ing more than one case. For the week ending
September 23 the following cases were reported:
29 of pulmonary tuberculosis, 16 of unclassified
pneumonia, 15 of malaria, 14 of endemic typhus
fever, 13 of bacillary dysentery, and 10 each of
mumps and typhoid fever. There were two cases
of mening-ococcus meningitis reported, one each
from Rapides and W^est Carroll Parishes. Five
cases of poliomyelitis were also listed this week,
no one parish having more than one case. The

week ending September 30 contained the venereal
disease statistics for the previous four weeks. Dur-
ing this time there were reported 1,340 cases of
syphilis, 1,319 of gonorrhea, 40 of chancroid, 19
of lymphopathia venereum, and 12 of granuloma
inguinale. In addition to these diseases that are
reported each month, the following diseases that
are reported weekly occurred in double figures,
36 of pulmonary tuberculosis, and 17 each of
measles and unclassified pneumonia. There were
thi-ee cases of meningococcus meningitis reported,
one from Jefferson and two from Orleans Parish.
Four more cases of poliomyelitis were also re-
ported, scattered over the state. The week of
October 7 still found pulmonary tuberculosis lead-
ing with 44 cases, followed by 16 each of endemic
typhus fever and unclassified pneumonia, 14 of
measles and 11 of bacillary dysentery. Ten of the
malaria cases were reported from military sources.
Of the unusual diseases there was listed one case
of meningococcus meningitis from Orleans Parish,
and one case of poliomyelitis from Caddo Parish.
■ o—

HEALTH OF NEW ORLEANS

The Bureau of the Census, Department of Com-
merce, reported for the week ending September 16
there were 115 deaths in the City of New Orleans.
Of these deaths there were 73 in the white popula-
tion and 42 in the colored. The total number of
deaths also comprised 11 deaths in children under
one year of age, six white and five colored. For
the week of September 23 there were 122 deaths,
divided 74 white, 48 nonwhite, with 13 deaths in
children under one year of age, four white and
nine negro. There was an increase in the total
number of deaths during the week of September 30,
136 people dying this week, of whom 82 were white
and 54 colored. The deaths among children under
one year of age was practically the same as the
previous week, being a total of 14, divided nine
white and four colored. The following week, Oc-
tober 7, there was a sharp decline in the total num-
ber of deaths. 104 people dying this week, divided
58 white and 46 nonwhite. Of these 11 deaths were
among infants under one year of age, seven white
and four colored.

DR. WILLIAM A, LURIE
(1881-1944)

Dr. Lurie died after a brief illness on Sunday,
September 25. He was born in Chicago in 1881,
and was a graduate of Rush Medical College of
that city. He came to New Orleans about 30 years
ago, and in latter years specialized in physiothe-
rapy and x-ray work.

240

Book Reviews

BOOK REVIEWS

Infections of the Peritoneum: By Bernhard Stein-
berg, M. D., New York, Paul B. Hoeber, Inc.,
1944. Pp. 455. Price, $8.00.

Peritoneal infections are a not infrequent source
of serious trouble to surgeons as well as to their
patients. Largely because the mechanisms of the
various developmental stages of the disease may be
misunderstood, the factors which might otherwise
be capable of successfully controlling the outcome
of these infections sometimes get beyond the pos-
sibility of medical manipulation. In the present
book Dr. Steinberg offers a comprehensive survey
and analysis of what is known in regard to the
pathogenesis of peritoneal infection and its treat-
ment.

The contents include a review of the changes in
physiology and pathology associated with the pro-
gressive stages in the infection ; the chemical and
hematological changes which are noted in the dis-
ease; special features of peritonitis in children and
penetrating injuries of the abdomen; diagnosis by
various means including x-rays ; also various
methods for the prevention and therapy of peri-
toneal infections. The approach is commendable,
as the author tries to present impartially the evi-
dence leading to the present-day point of view re-
garding the various aspects of the problem. The
figures and tables are instructive, while there is
a monographic list of reference at the end of each
chapter. A feature which may be of particular
value to clinicians is the series of well-presented
case reports, illustrating various factors in the de-
velopment of the different types of infection and
their outcome. The book should be read by sur-
geons, clinicians and bacteriologists interested in
the understanding of bacterial infections as they
develop in the individual patient.

Morris F. Shaffer, D. Phil.

Civilization and Disease: By Henry E. Sigerist,
M. D., D. Litt., LL.D. New York, Cornell Uni-
versity Press, 1943. Pp. 255. Price, $3.75.

The William H. Welch Professor of the History
of Medicine in the Johns Hopkins University, Dr.
Henry E. Sigerist, delivered the six Messenger
lectures under the auspices of Cornell University.
He has elaborated these lectures, which deal with
the evolution of civilization, into a book of twelve
chapters. In the first chapter Sigerist deals with
civilization as a factor in the genesis of disease.
In this he notes that a large part of the evolution
of disease from the time of the neolithic man to
the present date has been profoundly affected by
such factors as cleanliness, malnutrition, poverty,
housing, clothing and even gluttony. In chapter
two the relation of disease to economics is elaborat-
ed upon in some detail. Here he points out that
the poor man is the man who is most likely to

suffer from illness. People in the lower economic
scale are more susceptible to disease. Taking the
economic problem from the other point of view, he
presents evidence to show that disease itself pro-
duces a tremendous economic loss in the civilized
population of the country. In chapter three the
lecture has to do with disease and social life. In
this section he discusses such important diseases
as syphilis, tuberculosis, as well as mental dis-
ease and brings forth the concept that the modern
treatment of these disorders, which were at one
time looked upon as almost sufficient to ostracize
the individual sufferer, has now swerved towards
gentleness and kindness in the treatment of these
people who are sick, irrespective of the type of ill-
ness. In the subsequent chapters he discusses the
relationships that exist between disease and re-
ligion, disease and science, disease and literature,
music and art, all of which chapters are thought
provocative and presented in a style which makes
for easy and agreeable reading. The last chapter
on civilization against disease, the socialistic point
of view for which Dr. Sigerist has antagonized
many physicians, is accentuated. As a proponent
of governmental and subsidized medicine, however,
Sigerist has not presented this particular conten-
tion in a way that would irritate the average
physician, as he is moderate in his expressions but
does give one distinctly the impression that he
thinks socialized medicine should exist wherever
civilization exists and that the maintenance of the
health of the people is one of the primary func-
tions of the state. He has not ridden this hobby
hard in the book but does stress what so many
doctors believe, if there is inadequacy in medical
care for those of the lower income group it is more
dependent upon economic conditions and ignorance,
than it is upon lack of available and skilled physi-
cians, and their faulty distribution.

J. H. Musser, M. D.

Physical Medicine in General Practice : By Wil-

liam Bierman, M. D., New York, Paul B. Hoeber,
Inc., 1944. Pp. 654. Price, $7.50.

This book is essentially a therapeutic text of
physiotherapy designed to acquaint “the practi-
tioner in general medicine and special fields of
medicine with how he might us physical measures
with the others he employs in his effort to be of
greatest service to his patient”. The author does
this efficiently and without cluttering his material
with unessential historical data, lengthy discus-
sions on the physics of electricity, etc. He does
include physiological changes which result from
the application of physical agents. The author
points out that the absence of such physiological
observations in the past has led to an empirical
application of physical medicine with the “resultant

Book Revieivs

241

rejection of large sections of this phase of ther-
apy by the medical profession”. The sections on
application of physical medicine to the various
specialties are concise and contain much specific
information of therapeutic value.

The chapter on “The Conduct of Treatments” is
outstanding in its warnings and instructions as to
the avoidance of the various pitfalls of physio-
therapy.

The appendix which contains specifications for
physical therapy equipment as issued by the De-
partment of Hospitals of the city of New York
will be of value to anyone considering the pur-
chase of any apparatus. As a whole the book is
well worth reading and should enlighten many
members of the profession who are wont to con-
demn physical medicine as a tool of the charlatans.

Jack Wickstrom, M. D.

A Manual of Physical Therapy: By Richard

Kovacs, M. D., 3rd Edition thoroughly revised,
Philadelphia, Lea & Febiger, 1944. Pp. 309.
Price, $3.25.

This interesting manual is published in its 3rd
edition as a response to the increased interest in
physiotherapy which the rehabilitation of casual-
ties of the present war has stimulated. The pre-
vious editions were published under the title “Phy-
sical Therapy for Nurses” and, although com-
pletely revised, this present edition has many of
the “earmarks” of a teaching text (i.e.) questions
at the close of various sections useful in quizzing,
etc. The ilustrations are satisfactory and ade-
quate, but are not of equal caliber with the text.
The chapters on electrotherapy and light therapy
are very comprehensive and are well written. The
chapters on exercise, rest, relaxation and occupa-
tional therapy are extremely important, and al-
though well planned and well written, have not
been stressed sufficiently.

As a whole the book is a valuable contribution
to the literature on physiotherapy. It would serve
very admirably as a text for a much needed course
in physical medicine which is so conspicuously ab-
sent from the curricula of present medical educa-
tion. It is not as complete or comprehensive in
this field but serves adequately as a small manual.

Jack Wickstrom, M. D.

Tuberculosis of the Ear, Nose and Throat, includ-
ing the Larynx, the Trachea and the Bronchi:
By Mervin C. Myrson, M. D., Springfield, 111.,
Charles C. Thomas Co., 1944. Pp. 291. Price
$5.50.

This book covers tuberculosis of the ear, nose,
and throat completely, and otolaryngologists, in-
ternists, and practitioners will find it a valuable
guide. The exposition of the diagnosis, prognosis,
and treatment are well-written, and the therapeutic
measures are based on sound reasoning. The bron-

choscopist will find the chapter on tuberculosis of
the trachea and bronchus very interesting and
helpful.

Joseph Lau, M. D.

Hydronep/hrosis and Pyelitis of Pregnancy, An

Historical Review: By H. E. Robertson, M. D.,

Philadelphia, W. B. Saunders Co., 1944. Pp.

332. Price, $4.50.

One has to read this book to appreciate its value
and the enormous amount of labor and time en-
tailed in the compilation of the data presented.

The information dates from earliest times to the
present day recorded opinions relating to dilation
of the upper urinary tract and its associated in-
fection when present.

The material is presented in a most concise man-
ner with a complete bibliography appended.

This text has a place in the library of every
obstetrician and urologist.

Monroe Wolf, M. D.

Plaster of Paris Technic: By Edwin 0. Geckeler,
M. D., Baltimore, The Williams and Wilkins
Company, 1944. Pp. 220. Price, $3.00.

This is an interesting handbook on plaster of
paris technic adequately described by a well co-
ordinated text and illustrations; the materials
used, methods of manufacture and the various
technics employed in the application of casts and
splints necessary for the protection of fractures,
sprains, and other soft tissue injuries and infec-
tions. The technic of using plaster bandages as
well as the technic of the less familiar pattern
plaster are completely described.

The chapter devoted to errors and difficulties is
exceptionally valuable and points out the various
pitfalls associated with the use of plaster of paris;
the result of such errors and methods by which
they may be avoided.

It is interesting to note that although plaster is
used almost universally and has been used since
the earliest time for immobilization of fractures
and joint injuries, very little has been written on
the use of plaster and the technic of application.

The urgent need for a book written on the use
of plaster of paris in surgery and the technic is
filled by this interesting and well illustrated hand-
book. It is both suitable for instruction of gradu-
ate and under-graduate medical students; and will
prove of interest to every surgeon who has the oc-
casion to use plaster of paris.

Jack Wickstrom, M. D.

Bacterial Infection, with Special Reference to Den-
tal Practise: By J. L. T. Appleton, B. S.,

D. D. S., Sc. D., Philadelphia, Lea & Febiger,
1944. Pp. 498. Price, $7.00.

This is a book which merits well the success im-
plicit in the appearance of a third edition. The
purpose expressed in the title is achieved in marked

242

Book Reviews

degree in the text and in a manner to hold the
reader’s interest as well as to inform him of the
facts. The volume is divided into three parts. In
the first part there is an adequate but not ex-
cessive survey of the principles of bacteriology, the
chapters on antibacterial action of chemicals, sur-
gical antisepsis and asepsis being particularly
good. Part II treats the subject of infection as an
entity; that is to say, it discusses the various
modes of infection and the manifold defense
mechanisms of the body. The fundamentals of
immunology are in general summarized competent-
ly although there are a few places where the pre-
sentation may leave a reader new to the subject
with a perhaps erroneous impression. Part III
covers the present state of knowledge concerning
the common infections associated with the oral
cavity. This section is of exceptional interest and
excellence; the problems of oral disease and oral
hygiene are treated here in a fashion at once au-
thoritative yet objective. The physician interested
in problems of oral infection, the dentist who is
anxious to obtain modern knowledge of oral hy-
giene and to see it more widely disseminated, the
bacteriologist who wishes to have at hand in com-
pact form data on oral bacteriology derived often
from original sources which are not readily avail-
able to him — all will find themselves reading this

section with pleasure as well as profit. There are
many references to recent publications of original
research, which add greatly to the value of the
book. We agree with the sensible member of the
dental profession to whom we showed the volume
and who said, after a thorough inspection, “I must
buy this book at once for my reference library.”
Morris F. Shaffer, D. Phil.

PUBLICATIONS RECEIVED

W. B. Saunders Company, Philadelphia and
London : A Textbook of Pathology, by Robert

Allan Moore, M. D.

Grune & Stratton, Inc., New York: Neurology

of the Eye, Ear, Nose, and Throat, by E. A.
Spiegel, M. D. and I. Sommer, M. D.

Lea & Febiger, Philadelphia: Principles and

Practice of Surgery, by W. Wayne Babcock, M. D.

J. B. Lippincott Company, Philadelphia, London
and Montreal: Surgery of the Hand, by Sterling

Bunnell, M. D.

Froben Press, New York: History of Gynecol-

ogy, by Richard A. Leonardo, M. D., Ch. M., F. I.
C. S. Chronology of the Evolution of Plastic Sur-
gery, by Maxwell Maltz, B. S., M. B.. Sc. D.,
F. I. C. S.

Halstead, Kansas: Ventures in science of a

Country Surgeon, by Arthur E. Hertzler. M. D.

New Orleans Medical

and

Vol. 97 DECEMBER, 1944 No. 6

PROSTATIC OBSTRUCTION AND
SOME OF ITS COMMON
COMPLICATIONS*

EDGAR BURNS, M. D.f
New Orleans

The function of the prostate is purely
sexual. It does not affect the urinary tract
until it becomes diseased. The average
weight of the normal prostate at the age of
twenty is 15 grams. The size increases to
a maximum normal of 20 grams at the age
of fifty, at which time in 70 per cent of men
it undergoes natural atrophy corresponding
to the decrease in functional demand ; in
the remaining cases some degree of hyper-
trophy occurs. In about one-third of this
latter group of men who reach sixty years
of age progressive symptoms of obstruction
at the neck of the bladder will develop. The
remainder will have an enlarged prostate
producing relatively insignificant symp-
toms which are not progressive.

Infection, a frequent complication of hy-
pertrophy of the prostate, may in many of
the early cases be responsible for all of the
symptoms of which the patient complains,
particularly if the enlargement does not
produce obstructive symptoms. These pa-
tients complain of urinary discomfort, noc-
turia and often lumbosacral backache,
which may be promptly relieved by gentle
prostate massage. If the prostatic infection
has been eliminated, the hypertrophy may

*Read before the sixty-fifth annual meeting of
the Louisiana State Medical Society, New Orleans,
April 24-26, 1944.

fFrom the Department of Surgery, Tulane Uni-
versity School of Medicine and the Section of
Urology, Ochsner Clinic, New Orleans.

be disregarded as long as it does not pro-
duce obstructive symptoms.

Hypertrophy of the prostate may also
be complicated by prostatic calculi, which
are encountered far more often than was
formerly believed. They produce no pa-
thognomonic symptoms and in the majority
of cases gain clinical significance by simu-
lating prostatic carcinoma, furthering the
infection, predisposing to suppuration, cau-
sing hematospermia, hematuria, inguinal
pain or pain on ejaculation and producing
urinary obstruction alone or in association
with prostatic hypertrophy.

As the prostate progressively enlarges
the entrance from the bladder to the ure-
thra becomes elevated and contracted and
the prostatic urethra becomes elongated,
making it more difficult for the bladder to
empty itself. The result is enlargement of
the individual muscle bundles as a part of
nature’s attempt to compensate for the in-
creased effort necessary to accomplish the
urinary act. With enlargement of the mus-
cle bundles, the bladder wall becomes con-
siderably thickened and may be able to
function in a fairly normal manner for a
variable period of time.

In those patients suffering from acute
retention during this period, the bladder is
capable of resuming normal function as
soon as the obstruction has been removed.
In other cases, usually those with incom-
plete obstruction over a long period of time,
the bladder becomes decompensated in one
of two ways. In the first type, the entire
musculature of the bladder gives way, its
wall becomes thin and the bladder becomes
a huge hypotonic sac, often with a capacity

244

Burns — ir astatic Obstruction

of 4,000 to 5,000 c.c. The second type is
marked by the formation of diverticula,
either single or multiple, and, in many ca-
ses, the capacity of the diverticulum may
be as large as that of the normal bladder it-
self. The mechanical changes occurring in
the bladder wall as a result of prostatic ob-
struction are exaggerated by the presence
of infection. The organisms may invade
ihe bladder wall and in obstructions of long
standing, some of the musculature may be
replaced by scar tissue, thereby increasing
the likelihood of some degree of permanent
impairment of urinary function. A small
number of cases of prostatic obstruction
are complicated by vesical calculi, most of
which are probably the result of infection.
They can always be recognized during
routine preliminary studies and in the ma-
jority of cases do not seriously complicate
the management of the obstruction. There
is another group of cases in which more se-
rious secondary changes have occurred. If
an increased intravesical pressure is main-
tained for a long time, normal peristalsis
of the ureters is interfered with and even-
tually dilatation of these structures occurs.
With the removal of this normal protective
mechanism, the renal pelves become dilat-
ed, the cal ices become blunted and finally
the normal thickness of the renal cortex
is reduced, followed by considerable im-
pairment of renal function. Infection and
formation of calculi complicate stasis
in the kidneys, just as they do retention of
urine in the bladder. In such cases, the
changes that occur from chronic pyelone-
phritis add to the damage resulting from
mechanical back pressure. Renal calculi
in these cases, like those in the bladder, are
chiefly the result of infection and some-
times assume considerable clinical import-
ance.

Changes in the cardiovascular system
are common in the same age group that
suffer from prostatic obstruction. Hyper-
tension, angina pectoris, myocarditis and
cerebal and ocular changes are among the
most important complications. These are
not always secondary to prostatic obstruc-
tion but their clinical importance is exag-

gerated by long-standing urinary retention.
These patients require a much more detail-
ed physical examination than does the ave-
rage surgical patient. The general study
should be directed primarily toward the
cardiovascular system. Appropriate med-
ical investigation will establish whether or
not the cardiovascular system is compen-
sated. Patients with dependent edema and
other signs of congestive heart failure re-
quire medical treatment combined with
catheter drainage for whatever period
necessary for the cardiovascular system to
become stabilized.

Examination of the central nervous sy-
stem constitutes a part of the general medi-
cal study. The condition of the pupils and
reflexes and the presence or absence of
Romberg’s sign should be determined in or-
der to avoid overlooking some neurologic
lesion as the underlying factor in patient-
with urinary retention. Organic lesions of
the central nervous system, such as tabes,
may co-exist with prostatic hypertrophy
but the recognition of both conditions pre-
sents no special difficulty.

The genito-urinary tract should be tho-
roughly examined. The urine should be
studied for the presence of albumin, sugar,
casts, blood, pus and identification of the
organism if infection is present. Renal
function should be estimated by means of
one or more of the current standard me-
thods. It is my practice to do a routine
test in all instances and to make intrave-
nous urograms in those patients in whom
tumor or other associated renal lesions are
suspected. When the phenolphthalein test
is done, the patient voids at the end of the
first hour, at which time a small catheter
is passed to determine the amount of re-
sidual urine. Plain x-rays of the genito-
urinary tract should be made routinely to
determine the presence of stones in the
bladder, ureters or kidneys. Retrograde
c-ystograms should also be made in all cases.
These are taken in the anteroposterior and
right and left lateral positions. A fourth
plate is made after the solution has been al-
lowed to drain from the bladder through
the catheter. If a diverticulum is present,

Burns — Prostatic Obstruction

245

its size and location can be readily de-
termined and the evacuation film will fur-
nish information as to the ability of the
diverticulum to empty itself. By means of
rectal palpation the size, consistency and
mobility of both lobes of the prostate can
be determined. The benign hyperplastic
prostate is firm and elastic but the size of
the lobes as determined by rectal examina-
tion is not a criterion as to the degree of
their protrusion into the bladder. This ex-
amination, however, combined with the a-
mount of protrusion into the bladder, as
seen in the cystograms, will give an ade-
quately accurate estimation of the size of
the enlarged gland.

Sufficient information can be obtained
from these studies to make the indications
for treatment clear enough to obviate the
necessity of cystoscopic studies in the ma-
jority of cases. Cystoscopy under favor-
able conditions offers a most accurate
means of obtaining information about the
bladder and prostatic urethra. On the other
hand, nearly all of these patients are of
advanced age and many manifest some de-
gree of renal and cardiovascular damage.
Because instrumentation in such patients
is followed by an occasional serious reac-
tion, it is our policy to complete all other
studies first so that in the majority of cases
cystoscopy is not performed until the pa-
tient has been anesthetized for operation.
An exception to this routine is made when
the history, physical findings and x-ray
studies indicate the presence of a tumor in
the bladder or a diverticulum.

From information obtained by means of
a thorough physical examination including
a detailed study of the genito-urinary tract,
the patient should be classified therapeuti-
cally into one of two groups. The first
group, comprising those patients with good
cardiac and renal functions and uncompli-
cated obstruction at the bladder neck, may
be subjected to immediate operation. The
other group consists of those cases in which
there is poor renal function and some de-
gree of cardiac decompensation. If the
non-protein-nitrogen is above 50, the creati-
nine above 2 and the phthalein output below

30 per cent for the first hour, catheter
drainage should be continued until these
tests give normal results or until repeated
tests show that the readings have become
stabilized and that further improvement
may not be expected. Rest combined with
catheter drainage should be ordered for
those patients showing signs of congestive
heart failure in order to improve the car-
diovascular function as much as possible.

Acute infections in the prostate, bladder
and kidneys require drainage and the ad-
ministration of urinary antiseptics until
the acute phase has subsided. In these cases
infection can not be completely eradicated
until the obstruction has been removed.

In the majority of cases prostatic stones
do not seriously complicate operations on
the prostate although they may make sup-
rapubic enucleation more difficult because
of the associated fibrosis. Stones in the
bladder, as a rule, do not present any par-
ticular problem. If transurethral resection
is to be done, the stones should be crushed
with a lithotrite and their fragments wash-
ed out with an evacuator at the same time
the prostate is operated upon. The opera-
tion is only slightly prolonged and the post-
operative period is usually uncomplicated.
Only occasionally, because of acute infec-
tion in the bladder, an unusually large stone
or some abnormalities in the urethra, will
it become necessary to remove a urinary
stone by suprapubic cystostomy. Stones of
the kidneys and ureters should be treated
according to indications in the individual
case. Nothing should be done that might
transform a silent stone into an active one
in the presence of advanced prostatism.
Their presence should be noted and appro-
priate treatment instituted should they be-
come active at a later date. If a stone
blocks the ureter, the block should be prom-
ptly relieved as the majority of these cases
are associated with infection and serious
consequences may arise as a result of back
pressure pyelonephritis.

Diverticulum of the bladder is a compli-
cation of clinical importance in 6 per cent
of cases of prostatic obstruction. During
the preoperative studies an effort should be

246

Burns — Prostatic Obstruction

made to separate those that will remain si-
lent after the obstruction has been removed
from those that may be expected to compli-
cate the postoperative period. The cases
can not be classified from the size of the di-
verticulum alone. Many fairly large sacs
with a wide orifice will contract to the point
of almost complete obliteration or will pro-
duce no symptoms following removal of the
obstruction at the neck of the bladder. On
the other hand, diverticula with a large ca-
pacity and a narrow orifice communicating
with the bladder are usually of the reten-
tive type and require removal, pai'ticularly
if they are badly infected. Diverticulec-
tomy should also be done in those cases with
complicating stones or neoplasms. When
diverticulectomy is clearly indicated, it has
been our routine practice to remove the di-
verticulum first and perform the operation
on the prostate at a later date. We can
think of no reason for reversing this proce-
dure. Within a week to ten days following
diverticulectomy, transurethral resection or
suprapubic prostatectomy may be perform-
ed. If the prostatic obstruction is to be re-
lieved by transurethral resection, the supra-
pubic catheter may be removed at the same
time and the wound allowed to close. If
sufficient tissue to relieve the obstruction
has been removed, the suprapubic wound
promptly heals.

The type of operation to be performed on
the prostate is a matter of individual choice
and is based largely on the training and ex-
perience of the operator. The three me-
thods of approach are suprapubic, perineal
and transurethral. Suprapubic prostatec-
tomy is perhaps better adapted to the facili-
ties of the average hospital and to the skill
of the majority of surgeons. It is a simpler
technical procedure than either of the oth-
ers. Its value as a relatively safe and sat-
isfactory method of removing a large, en-
capsulated, benign prostatic tumor is well
established. It is common practice to do a
preliminary suprapubic cystostomy for the
purpose of decompressing the urinary tract,
improving renal function, controlling infec-
tion and otherwise improving the general
health of the patient. In many cases, pros-

tatectomy may be done within a week or ten
days after suprapubic cystostomy. Other
patients may require a longer period of sup-
rapubic drainage before the local condition
and the general health of the patient have
sufficiently improved for the safe perform-
ance of the second stage of the operation.
For the patients who are considered ex-
cellent risks, suprapubic prostatectomy may
be safely performed in one stage without
preliminary suprapubic cystostomy.

Young1 and a number of his pupils be-
lieve that perineal prostatectomy is a more
benign operation than suprapubic enuclea-
tion in skilled hands. It is a highly techni-
cal procedure and, when performed by the
untrained surgeon, is liable to be followed
by rectal injury, incontinence of urine and
urinary fistulas. A small number of cases
with early carcinoma of the prostate are
seen before the malignancy breaks through
the capsule. For this group of cases the
perineal operation is the method of choice.
The prostate with its capsule, the seminal
vesicles and if necessary a portion of the
trigone may be removed. Belt2 and others
have reported cures of this method which
could not be accomplished by another type
of approach.

Transurethral resection, attempted at in-
tervals for many years, but discarded for
lack of adequate instruments, was popular-
ized by Davis in 1931, by which time an
electrosurgical unit and visual instruments
had been developed to the extent that this
procedure could be performed with relative
safety. The extent to which transurethral
resection is used is influenced largely by
the various training centers for urologists.
In schools where suprapubic or perineal
prostatectomy is the method of choice there
will be few cases in which transurethral
resection is indicated. In other centers
where wide experience has been gained in
the use of transurethral instruments, this
approach is used as the method of choice.
On our own service at Tulane University
we started doing transurethral resection in
1932, choosing at first cases with bars,
small lobes and advanced carcinoma, the
larger benign obstructions being treated by

Burns — Prostatic Obstruction

247

suprapubic enucleation. With further ex-
perience we have added larger and larger
obstructions to the group in which trans-
urethral resection is indicated until now,
at the end of twelve years, it is our method
of choice in all except the unusually large
benign prostatic hypertrophies.

An attempt is made at the present time
to perform as complete a prostatectomy as
can be done by any other method of ap-
proach. The average weight of the enu-
cleated, benign hypertrophic prostate is a-
bout 50 grams and the average weight of
tissue removed from 100 cases on the Tu-
lane Service at Charity Hospital in New
Orleans was 44.6 grams. Thus, almost
complete removal was accomplished in this
group of cases. Most patients who have
had transurethral resection are permitted
out of bed on the fourth or fifth postopera-
tive day. This is an important factor in
handling men of this age group in whom
a prolonged stay in bed would predispose to
pulmonary complications. In the begin-
ning, because an insufficient amount of tis-
sue was removed at the first operation, in
about 10 per cent of patients a second op-
eration had to be performed within a week
or ten days before they could urinate. At
the present time it is nexessary to subject
only an occasional patient to a second oper-
ation. Of course, in certain cases the two-
stage operation may be selected, either be-
cause of the size of the gland or because the
age and general condition of the patients
make a prolonged stay on the operating
table undesirable. Such patients should
never be on the table for more than an
hour. The second operation is usually fol-
lowed by little or no postoperative reaction.
The blood vessels and lymphatics have been
sealed off by the first operation and in the
majority of cases the catheter may be re-
moved and the patient allowed to get up on
the following day. The mortality rate from
transurethral prostatectomy is less than 5)
per cent, which compares favorably with
the other methods.

It should be pointed out that a number
of patients who are poor cardiorenal risks,
formerly condemned to the use of a perma-

nent suprapubic tube, can now be treated
by transurethral resection. Furthermore,
there are a few patients, who, following su-
prapublic cystostomy, improve enough so
that transurethral resection can be done
and normal urination restored. The same
results must be obtained by transurethral
resection as can be obtained by either per-
ineal or suprapubic enucleation. These pa-
tients must be able to start the stream with-
out hesitating and without straining. The
stream must be full and strong and the pa-
tients must have the feeling of relief that
comes at the end of the urinary act when
the bladder is empty. Nocturia should be
reduced to once or twice at the end of six
or eight weeks and the urine should be
sterile in the majority of cases by the end
of three months.

REFERENCES

1. Young, H. H. : The radical cure of cancer of the

prostate, Surg. Gynee. & Obst., 64 :472, 1937.

2. Belt, E. : Radical perineal prostatectomy in early

carcinoma of the prostate, J. Urol., 48 :2S7, 1942.

DISCUSSION

Dr. U. S. Hargrove (Baton Rouge) : As usual,

Dr. Burns has given us a very thorough and com-
plete exposition of this subject; a resume of present
methods of treating prostatic obstruction, and I
hesitate to say anything but to praise his paper.

I have picked out a few points for argument.
Like a radio announcer introducing a political
speaker— these are my own opinions and do not
necessarily represent the opinions of anybody else.

In regard to cystoscoping prostatic patients, Dr.
Burns and probably the majority of ulorogists feel
that it is unnecessary to cystoscope until the pa-
tient is anesthetized and you are ready to operate.
I believe this is possibly not a valid procedure,
because I think you can obtain more accurate in-
formation by cystoscopy before operation.

Another point is stones accompanying prostatic
obstruction. If the bladder is seriously infected,
with stones and prostatic obstruction, I feel the
morbidity is less if the stones are removed by su-
prapubic operation rather than instrumentally. It
seems that sometimes suprapubic opening of the
bladder should be avoided as long as possible and
at other times it is referred to as a minor pro-
cedure. I do not see any good reason not to open
the bladder suprapublically if there is real indica-
tion for same. Also if the bladder must be opened
for some other reason, such as the presence of di-
verticulum, I do not believe that it is entirely
logical to complete the operation by transurethral
resection. If the bladder is opened to remove a
diverticulum, it is probably best to complete the

248

Bendel — Pelvic Inflammatory Diseases

operation by suprapubic enucleation. This takes
up very little time if a large gland is present; less
time than a transurethral operation.

The 'use of sulfa drugs was mentioned in dis-
cussion of gynecologic disorderSi H /believe (in
prostatitis, in the acute infections, sulfa drugs
are very useful. In chronic infection of the pros-
tate, sulfa drugs have very little, if any, place.

One other point I would like to make is that the
patient’s referring physician should not try to in-
fluence the surgeon as to what type of procedure
to use in handling the case. The transurethral
operation is so publicized that the general prac-
titioner may get the idea it is always the best plan
of operation. There are complications that may
arise, and the patient and the referring physician
should not try to influence the type of operation
employed. One complication of transurethral sur-
gery is delayed hemorrhage, arising two or three
or more weeks after operation. That is a compli-
cation I have not encountered in suprapubic
enucleation.

Dr. J. R. Stamper (Shreveport) : I consider Dr.
Burns’ paper well delivered and complete and it is
not necessary to discuss the paper but I thought
perhaps it would be worth while, with his permis-
sion, to sidestep the paper and discuss malignancy
of the prostate just for a minute or so since he did
not get to that.

Our pathologist tells us that about one-fifth of
our cases handled surgically are malignant, and we
feel we have a good pathologist. I am not going
into the management of malignant prostates but
only offer a word of warning since there is not
time here to discuss it.

Since the hormone treatment has come into play
for malignant prostates it has been dramatic in its
preliminary effect. There is going to be a great
tendency with general practitioners, as well as
urologists, to begin hormone treatment early with-
out doing something to impress the patient with
the diagnosis or impress him with the wray he has
to deal with it in the future. I think what we
should do in the beginning is to discuss this
thoroughly with the patient and come to an under-
standing about the future management, otherwise
he will improve so rapidly that he will decide the
doctor has made a mistake and the diagnosis is
wrong.

The next time the doctor is consulted, the dis-
ease is much further advanced and more difficult
to control. It is my policy to postpone treatment
until the diagnosis is thoroughly established, and
the patient is convinced of that fact and will-
ing to go through with the operation, which is
resection where there is obstructive symptoms, and
it is a fact they do better after a complete resection.
Then we have the hormone treatment, castration,
as well as radiation, either deep therapy or radium
seed. All of these procedures are effective and

very important in various cases and stages of the
disease.

Dr. Edgar Burns (in closing) : The question
raised by Dr. Hargrove is a legitimate one. Cysto-
scopy, performed as he described it, is done as a
part of the diagnostic procedure in many of the best
urologic clinics in the country. We feel, however,
that sufficient information can be obtained by care-
ful rectal palpation and complete x-ray studies of
the urinary tract to make the indications for treat-
ment clear and in the majority of cases instru-
mentation is unnecessary. In regard to stones in
the bladder, it has been our policy for a long time
to crush those in which there were no contraindi-
cations to the use of a lithotrite. In answer to his
question on enucleating the prostate after the blad-
der bas been opened for the purpose of doing a
diverticulectomy, I would like to say that it is our
policy to enucleate the unusually large, benign
prostates. On the other hand, if the obstruction is
small and especially if the prostate is associated
with a great deal of fibrosis as a result of previous
infection, I am convinced that transurethral resec-
tion is easier to carry out and is followed by much
less postoperative reaction.

In regard to delayed hemorrhage in cases in
which prostatic resection has been done, I am quite
sure the bleeding as a rule comes from a small
nubbin of prostatic tissue that has not been re-
moved. I think when the prostate is resected down
to the capsule late postoperative hemorrhage will
not be encountered any more often than after a
perfectly clean prostatic enucleation.

In reference to Dr. Stamper’s question of malig-
nancy, I did not have time to cover that portion of
my paper, but it will appear in the published
article. We have used stilbestrol in a great number
of cases of malignancy and up to the present time
the results have certainly justified its use. We are
performing castration in every case in which it is
possible. If, for one reason or another, it cannot
be done, stilbestrol may be substituted with very
satisfactory results.

— — — o

PELVIC INFLAMMATORY DISEASES*

WILLIAM L. BENDEL, M. D.

Monroe, La.

I realize there is not much to tell you
that you already do not know regarding
pelvic inflammatory diseases but at times

*Read before the sixty-fifth annual meeting of
the Louisiana State Medical Society, New Orleans,
April 24-26, 1944.

Bendel — Pelvic Inflammatory Diseases

249

it is a good idea to review and refresh our
minds on such an important subject to both
gynecologists and obstetricians.

Infection of the female genital organs
makes up a large group of the diseases pe-
culiar to woman, and their pathology and
treatment are so distinct because of the spe-
cial anatomy of the genital tract.

By discussing the inflammatory diseases
which are directly the result of labor, abor-
tion and mixed or gonorrheal infection
spreading from acute cervical and endom-
etrial lesions, it is fitting to review briefly
the infections of the vulva, introitus, vagina
and cervix.

Skenes gland or para-urethral ducts are
two small tubules which lie on either side
of the female urethra near the floor and
extend backward from the meatus urinarius
for about three-fourths of an inch — these
ducts open just anterior to the center of the
urethral lips. Their chief interest lies in
the fact that gonorrheal invasion of these
ducts is the most persistent lesion with
which the gynecologist has to deal, for the
gonoccocus may remain indefinitely buried
beneath the lining cells of the tubule. The
treatment is destruction of the gland by
injection, cauterization or electric coagu-
lation.

The Bartholin duct which is found within
the vulvo-vaginal orifices is common and
frequent cause of continuing infection. The
duct leads to the gland and both must be
removed if infected.

The different kinds of vulvitis : simple,
gonorrheal specific, follicular, and diabetic,
are just mentioned, but will not be dis-
cussed here. I would like to mention in
passing, however, the method of treatment
in specific trichomonas vaginitis that has
given us best results. This consists of
scrubbing of vagina and external parts with
tincture of green soap and water, then
paint vaginal tract and external parts with
1 per cent aqueous gentian violet, insert
No. 11 veterinarian capsule containing 80
per cent betalactose and 20 per cent boric
acid and then insert a tampon to prevent
the capsule from falling out. Douches are
advised for cleanliness and comfort.

Endocervicitis is now recognized to be the
chief cause of sterility in the female, while
its importance in the causation of abortion
must not be underestimated. Furthermore,
chronic erosions occurring on the portio
of the non-lacerated cervix and upon the
everted lip of the torn cervix are precursors
of cancer of the cervix. Treatment is es-
sentially to remove the cause ; cauterization
or removal.

Neisser has said that with the exception
of measles, gonorrhea is the most wide-
spread of diseases. Norris has said it is
the most potent factor in the production
of involuntary race suicide and by sterili-
zation and abortion does more to depopulate
this country than does any other cause.

According to Menge, cervical infection is
found in about 80 per cent of all acute cases
and in 95 per cent of all chronic cases.

While specific infection in its acute state
differs but little from other pyogenic in-
flammation, the peculiar characteristic of
the gonococcus — seeking as it does the
glandular recesses, makes its management
and cure more difficult. In the treatment
of the acute state every effort must be made
to prevent its upward extension along the
mucous surfaces. We must attempt to com-
pletely eradicate the infection by destruc-
tion of the gonococcus of the involved areas.

Acute puerperal and non-puerperal in-
fection of the female genital organs and
their sequlae make up the largest group of
diseases peculiar to women with which
gynecologists and surgeons have to deal.

Infection of the female genitalia takes
place either from without through known
avenues of entry or from within by a hema-
togeneous route in which case the original
focus may be remote from the pelvis. The
peculiar anatomic arrangement of the gen-
erative organs in women constantly exposed
as they are to infection and trauma directly
favors inflammatory changes. Further-
more, certain periods in a woman’s life tend
to subject her to infection of different types
and in different locations. Pelvic infec-
tions, as do infections in other tissues, re-
sult from the introduction and propagation
of infectious organisms into a favorable

250

Bendel — Pelvic Inflammatory Diseases

soil. In general we have two classes of in-
fective bacteria, the cocci and the bacilli.
In the former class are found the gonococci,
streptococci, staphylococci and pneumococci
and in the latter the D. coli communis and
B. aerogenes capsidatus. Regelius has found
the following types of bacteria more or less
constant in the flora of the vulva, ameba
streptococcic, and staphylococcic, the B.
coli communis, amebic streptococcic and
staphylococcic and B. capsidatus. All ob-
servers agree that the cavity of the uterus
is free from bacteria during normal preg-
nancy. but during the puerperium organ-
isms undoubtedly ascend into the uterus
even in women who have not been exam-
ined. The vulva, vagina and cervix are the
habitat of numberless non-pathogenic bac-
teria which are normal to these locations.
It is conceded that though these non-patho-
genic bacteria in the vagina or around the
vulva, and vestibule are innocuous in these
localities, that if they are introduced be-
yond these extremities and into a favorable
culture medium by any agency they become
pathogenic.

As has been stated, the uterus is normal-
ly sterile, but during labor, abortion, the
puerperium and menstruation the reaction
of the vaginal secretion is changed by the
addition of blood, or mucus and becomes
less resistant. The organisms which are
ordinarily inactive multiply and when an
avenue of entrance is made, as by trauma,
infection follows. Septic infections which
occur in connection with labor, abortion or
the puerperium present characteristic fea-
tures. The clinical cause is determined
first by the character, life history and hab-
its of the infecting bacteria and secondly
the anatomic conditions .which exist during
these periods. Hence in considering pelvic
infections in women we necessarily have to
study them in the following classes: (a)
puerperal infections; (b) non-puerperal in-
fections; (c) gonococcic infections.

Puerperal infection, like any other infec-
tion, depends upon the inoculation of the
puerperal wound by a bacteria. It may be
given as: (1) a wound inoculation; (2) lo-
cal process illustrated in the infected perin-

eum, cervix and endometrium in which
there is tissue reaction which limits the
extension of the infective process; (3) the
spreading of the infection beyond the
wound area which may run through blood
vessels in which case it may manifest itself
as a thrombophlebitis, pyemia or bacteri-
emia or through lymphatics producing
parametritis, peritonitis and so on.

Traumatisms of the birth canal, which
may occur during the course of labor, in-
clude rupture of the uterus, laceration of
the cervix, vagina, vulva and perineum.
These are all contused and lacerated
wounds, consequently the tissue resistance
is lowered and bacterial inoculation and in-
fective invasions are favored. Ordinarily
during the course of normal involution with
proper uterine contraction and drainage the
uterus is capable of sterilizing its cavity.
However, when the contraction and retrac-
tion are poor the contained bacteria multi-
ply with amazing rapidity, owing to re-
tained blood clots which act as a culture
media, but many gain entrance to the uter-
ine and para-uterine tissues as has been
shown by Sampson through the lymph chan-
nels and venous radicles.

The endometrium after labor or abortion
should be considered as a traumatized
wound undergoing the normal process of
wound repair and may be infected by patho-
genic micro-organisrns in which case it is
virtually a large puerperal ulcer. It must
be supposed that the presence of necrotic
decidua or even a piece of letained placenta
within the cavity of the uterus will produce
an endometritis. In order to have an in-
flammatory reaction there must be infec-
tion. Retained products of conception sim-
ply act as culture media for bacteria and
prevent proper retraction and contraction
cf the uterus which in turn diminishes the
normal protection of the individual against
bacterial invasion. It is easy to understand
at the close of labor the entire interior of
the uterus is one large wound. Nature,
however, accomplishes exfoliation by the
development of the granulation wall which
separated the dead from the living tissues.

Bendel — Pelvic Inflammatory Diseases

251

In a large majority of cases the bank of
granulation tissue and leukocytes is suffi-
cient to limit the infection to the interior
of the uterus, unless nature’s efforts are
interfered with by the meddlesome obstet-
rician who insists that because there is ne-
crotic material within the uterus, even
though it be the result of nature’s conserva-
tive starvation process, he must remove it
and by so doing break through the barrier
which nature has placed there to protect
the organ against the infecting organism.
The infecting organisms may be a sapro-
phytic or pyogenic coccus or both may be
present. The severity of the infection de-
pends upon tissue resistance and the viru-
lence of the infecting cocci.

Experience has shown us that any sort
of trauma to the delicate granulation wall,
which is confining the infection within the
uterus, opens avenues of extension and that
lateral parametritis is a constant sequel of
attempts at digital or instrumental evacua-
tion. It does no harm to remove sterile
contents, but manipulation always spreads
infection when the content is already in-
fected.

When we find it necessary to remove
secondines because the retained particles
are infected, causing bleeding, fever, and
so forth, we do so very carefully and never
with a sharp curette and only with a sponge
forceps, gently used.

Pelvic cellulitis or parametritis is an in-
flammatory reaction of the pelvic cellular
tissue to bacterial invasion. The bacteria
reach the parametrium through the lymph
stream and exert a tissue reaction in which
serum, leukocytes and round tissue cells are
poured out, producing a local inflammatory
swelling.

The treatment of puerperal infections
may be divided into prophylactic and cura-
tive. Preventive measures play such an
important role and so much can be done
during pregnancy and labor to prevent the
occurrence of the infection, that we all
know what these measures should be. The
curative treatment is based on proper recog-
nition of the natural pathology which must
be given its place, for the interior of the

uterus is a large wound surface and is the
principal port of entry for bacterial inva-
sion and that the interior of the uterus if
left to itself undisturbed by interference or
trauma, is, except in the presence of the
most virulent bacteria, competent to defend
itself against the invading organisms. One
can see the fruitlessness and fallacy of in-
tra-uterine manipulation. Treatment is
along physiologic needs. This includes (1)
postural drainage; (2) secure proper uter-
ine contraction by ice caps to abdomen.
Pituitrin and ergot aid natural emptying
of uterus and by position and turning over
at times. No irrigation should be used.
Use of transfusions and sulfa group of
drugs may be helpful. Rest, combatting
temperatures, tonic and mild laxatives are
useful measures.

Salpingitis is an inflammation of the fal-
lopian tube which is nearly always second-
ary to infection of the uterus or of the
peritoneum. The infecting organisms may
reach the tube by four different routes :
(1) They may gain access to the lumen of
the tube from the interior of the uterus,
as in acute gonorrheal infection of the en-
dometrium; (2) they may reach the tube
from the peritoneal cavity by way of the
abdominal ostium as in streptococci and
staplylococcic cellulitis and peritonitis fol-
lowing childbirth and abortion. By this
route the bacteria may be sucked in from
the peritoneum by the ciliary current at
the ostium, in which case the tubal infec-
tion is secondary to the peritonitis or they
may produce an endosalpingitis by exten-
sion through the lymph channels of the
broad ligament. (3) They may gain access
through the tube wall, when intestinal ad-
hesions are present, as in peritonitis follow-
ing appendicular and intestinal perfora-
tions; (4) finally, bacteria may invade the
tube through the blood stream or lymph
channels as is the case in primary tuber-
cular salpingitis. Syphilis and gonorrhea
are the most common causes of tubal in-
flammation and various micro-organisms
are found. The gonococcus is the organism
most frequently met with, producing from
60 to 70 per cent of all tubal infections. The

252

Bendel — Pelvic Inflammatory Diseases

infection in these cases always ascends from
the interior of the uterus. Infection by the
streptococcus and staphylococcus is also
generally invasion from below. Salpingitis
occurring before puberty is always gonor-
rheal or tubercular in origin, although it is
possible for a child to have salpingitis fol-
lowing the exanthemata. The inflammation
is usually bilateral. Mixed infections have
the most serious effect and produce the
greatest tissue reaction in the tubal struc-
tures and leaves some permanent pathology.

The termination of acute salpingitis may
be in resolution as the inflammation may
subside completely, leaving behind only a
slight fibrous thickening of the tube wall
and few adhesions about the fimbriated
extremity.

Gonorrheal infections, uncomplicated by
other cocci, frequently terminate in com-
plete regeneration of the tube. Mixed in-
fections take longer to subside and always
permanently damage the tube. Pregnancy
is unlikely to follow in this group.

As a result of intestinal adhesions to the
tube, there is often a secondary infection
by the B. coli. When this occurs the origi-
nal infecting organism frequently dies out
and after a time the B. coli also dies, and
there is left a tube distended with pus, often
foul smelling but sterile.

Hydis’ work has shown that in gonor-
rheal infections the contained pus is sterile
from six weeks to three months, but the
streptococcus may live in the tissues for
years.

In chronic cases leukorrhea, premature
pain, premenstrual abdominal soreness,
dyspareunia and sterility alone or in com-
bination are the symptoms for which the
patient seeks relief. All the symptoms are
exaggerated by walking and standing. Re-
current attacks of pelvic peritonitis are
characteristic of subacute tubal inflamma-
tion, and occur most frequently at or near
the menstrual periods.

Probably in no other pelvic condition is
the prognosis so dependent on an intelligent
appreciation of the life history of the in-
fecting organism and the pathology which

it produces as in the inflammation of the
fallopian tubes.

Gonorrheal salpingitis is seldom danger-
ous to life, for there is a definite tendency
for the inflammatory reaction to be con-
fined to areas within the true pelvis. Strep-
tococcus salpingitis has a definite primary
mortality, and owing to the longevity of
the streptococcus greater virulence and
stronger tendency to extend beyond the con-
fines of the true pelvis. Rupture of a pyo-
salpinx may take place into the peritoneal
cavity, producing fatal, spreading peritoni-
tis or may rupture into and be walled off
in the cul-de-sac of Douglas where it causes
an active reaction.

The treatment of salpingitis must be con-
sidered under the following headings: (1)
Acute; (2) acute exacerbation of chronic
salpingitis; (3) chronic salpingitis — pallia-
tive, conservative and radical.

No patient with acute salpingitis needs
operation.

Experience has shown that about 80 per
cent of women with pelvic inflammatory
disease may be made symptom-free by con-
servative measures. Hence operation is
considered only after adequate and diligent
conservative measures have failed. Suc-
cessful conservative therapy can never be
carried out in ambulatory patients.

In acute adnexal inflammation, operation
is contraindicated not only because of the
possibility of peritonitis, but also because
in the majority of cases conservative meas-
ures provide a cure. Occasionally" the symp-
toms cannot be relieved without operation
and . even in these patients conservative
treatment has an advantage in that the
process has time to become chronic. The
necessary operation will then be relieved of
much of its dangers. Operation is indi-
cated in :

(a) In the presence of peritonitis.
Rapid, weak pulse, high temperature, pain
and rigidity of entire abdominal wall,
vomiting, constipation and no localization
of tumor. Especially bad are non-gonor-
rheal infections because in the pyogenic in-
fections of the adnexa there is no walling

Bendel — Pelvic Inflammatory Diseases

253

off of the process by a fibrinous exudate
and the pyogenic organiism tend to produce
necrosis and perforation of the primary
focus. The operation should be a laparo-
tomy, that is, extirpation of the lesion which
is the source for peritonitis, removal of the
pus and drainage.

(b) Early operation in the presence of
large fluctuating abscesses of the tube and
ovary in the pouch of Douglas. The opera-
tion of choice should be vaginal puncture
and drainage, and should be done as soon
as possible. Pyogenic abscesses in con-
tradistinction to the gonorrheal abscess are
almost unilocular. Frequently in my ex-
perience at a later date, usually six months,
a secondary abdominal operation has to be
performed.

(c) Operation is indicated in the pres-
ence of small purulent tumors if the fever-
free interval gradually becomes shorter and
recurrence appears on the slightest provo-
cation or apparently without cause, espe-
cially if the patient’s condition is poor. Va-
ginal drainage is usually not indicated be-
cause of the small tumor and its inaccessi-
bility.

(d) In the chronic stages, especially if
there are symptoms still present. The ab-
dominal operation is performed, conserv-
ing as much ovarian tissue as possible. This
operation is performed especially if the
symptoms cannot be relieved by adequate
and repeated trials of conservative therapy.
It is true in the chronic inflammations one
must be sure that the symptoms present are
caused by adnexal lesions and not by extra-
genital factors. It may be impossible to
foretell whether there is pus present or
whether pyogenic organisms may be present
in the pus. In more than 50 per cent of
cases the pus is sterile and in some cases
only the gonococcus in the pus is found.
When pyogenic organisms are present there
is danger of peritonitis. There are occa-
sions when operation does not relieve the
symptoms. The development of exudate or
formation of adhesions about the stump
may make the operation unsuccessful. If
parametrial exudate is present it does not
offer a good postoperative outlook, as symp-

toms will continue due to parametritis. The
pyogenic infections are considered more
serious but gonorrheal infection may also
have a secondary infection, therefore for
this reason, the etiology of pelvic inflam-
matory disease should not influence the de-
cision for operation.

Occasionally there arises a situation
where there is a right sided adnexal tumor
and the left side is normal. Should it be
removed there must be decided whether
the patient is young or not and desires fu-
ture pregnancy. It is true the tube may
appear normal and not be so, and one would
be sure of no recurrence if it were removed.
The operator must make his own decisions.
In removing the tubes it is important to
make a wedge-shaped incision in the uterus
to be sure to remove the interstitial part of
the tube. In determining the time for op-
eration it is best performed when the ad-
nexal tumor no longer contains virulent or-
ganisms which migh cause postoperative
complications. Of course, it is not easy to
prove that this danger is not present ; how-
ever, there are a number of symptoms and
methods of study by which one may deter-
mine whether the adnexal inflammation is
quiescent.

(a) Long fever-free intervals. Viru-
lence of bacteria diminishes in closed off
peritoneal organs and abscesses and bac-
teria in these lesions die and disappear in
six to twelve months.

(b) If at menstrual time there is no re-
turn of pain or fever.

(c) Vaginal examination or diathermy
will not cause pain or fever.

(d) There is usually no leukocytosis.

(e) Blood sedimentation test. A rapid
sedimentation of the red corpuscles indi-
cates activity. Any one of these signs is
no proof of the activity of the adnexal dis-
ease when considered alone. If, however,
many or all of them indicate that the in-
flammation is still active, operation should
be postponed if possible until a more fa-
vorable time.

Time does much toward allowing the pel-
vic organs to reassure their normal func-

254

Bendel — Pelvic Inflammatory Diseases

tion. Watchful waiting is therefore the
slogan in acute inflammation. Before any
operative procedure is justifiable all acute
symptoms must have subsided and the
morning and evening temperatures must be
normal for a period of at least three weeks.
All exudates must have been absorbed or if
some still persist they must be hard and in-
tensive. Pelvic examination will not, if
these conditions are fulfilled, excite an ex-
acerbation of temperature or an increase
in leukocyte count. The leukocyte count
should be less than 11,000 and polymorph-
onuclears less than 75 and sedimentation
test normal.

The treatment of chronic salpingitis may
be palliative, conservative or radical. Time
affects a symptomatic cure in a large num-
ber of tubal inflammations, especially if the
gonococcus is the sole infecting agent.

Palliative treatment consists in the main-
tenance of the woman’s general health by
tonics, fresh air, and proper rest. The
regulation of the intestinal tract should be
accomplished by the use of systematic ab-
dominal exercise, proper diet and adminis-
tration of mineral oil and enemata. The
use of hot douches to absorb exudates, and
use of sulfa group drugs, transfusions or
infusions may be used as needed. The use of
diathermy, fever therapy by diathermy, or
foreign proteins, Elliott bag treatment all
have their advocates. The treatment of pus
tubes by conservative methods demands
that the patient be an invalid for consider-
able time, at least several months. If she
is fortunately enough situated to sacrifice
time for the possibility of child-bearing,
conservation is continued.

The operative treatment of chronic sal-
pingitis includes: (1) salpingostomy or

partial resection of one or both tubes; (2)
salpingectomy or ablation of one or both
tubes with retention of the uterus and one
or both ovaries or part of the uterus with
one or both ovaries to maintain the men-
strual function.

The physician will do well to avoid active
treatment of the vagina, or cervix, or mani-
pulation of the pelvic structures, which, by
its trauma or disturbance of the protective

barrier, may permit the upward passage of
the infection.

DISCUSSION

Dr. T. B. Sellers (New Orleans) : Dr. Bendel
has presented a most instructive paper on a timely
subject. I can endorse practically everything that
he has presented in his most exhaustive paper. Of
course, the subject matter of his paper is volumi-
nous and naturally time would not permit him to
go into a detailed discussion. I shall endeavor to
elaborate on a few points that he has presented.

Neisserian infection is no longer a serious gyne-
cologic problem if it is diagnosed early and if
cooperation of the patient can be secured. I agree
with Dr. Bendel that absolute rest, including sex-
ual rest, is necessary and as soon as the acute
symptoms subside, which can be hastened by the
use of sulfa drugs, then the eradication of the
infection in the Skene’s glands and endocervical
glands should be carried out.

Before any surgical procedure is attempted in
subacute or gonorrheal infections of the cervix or
Skene’s glands, the patient should be given one of
the sulfa drugs and the blood level brought up to
seven or ten and kept there for at least eight to
ten days following the surgical procedure. I am
sure that Dr. Bendel will bear me out that coni-
zation or cauterization of a subacute or' acute
cervix is a very dangerous procedure; in doubtful
cases, treat as you would a known positive.

There are three main causes of postabortal or
postpartal infection: first, endogenous infection
where the anaerobic bacteria play an important
role. Second, blood loss at delivery or its equiva-
lent, severe anemia complicating pregnancy.
Third, trauma due to prolonged or difficult labor
or to the improper management of postabortal
cases.

Much can be done along prophylactic lines. The
gynecologist should lealize the potential danger
of endocervical infection and eradicate infected
endocervical glands in all women who come under
his care before pregnancy. Multiple transfusions
should be given whenever there is anemia, regard-
less of its cause. Sulfa drugs should be given be-
fore the patient is febrile, as a preventive measure.

In the neglected cases, with extensive involve-
ment, that are referred to or come to the gyne-
cologist, again the sulfa drug is of inestimable
value. Of course do not overlook the fact that
when giving sulfa drugs one must force fluids and
give heavy doses of alkalies with it. Transfusions
and the other supportive measures used prior to
the advent of the sulfa drugs should also be car-
ried out. Short wave diathermy, through the pel-
vis, has replaced all other methods of heat to the
pelvis, except douches.

Dr. John F. Dicks (New Orleans) : While sitting
here listening to Dr. Bendel’s paper I have jotted

Bendel — Pelvic Inflammatory Diseases

255

down some of my impressions. First, Dr. Bendel
has covered a great deal of territory and done it
well. However I am going to open this discussion
by taking issue with some of the things that he
has said.

Dr. Bendel states, and I quote: “Experience has
shown that 80 per cent of women with pelvic in-
flammatory disease may be made symptom free
by conservative measures.” I admire Dr. Bendel’s
conservatism and optimism but my experience does
not concur. I would amend that statement to
read, “Possibly 50 per cent of women with pelvic
inflammatory disease may be rendered temporarily
symptom free by conservative treatment.”

As I grow older I become less optimistic about
curing pelvic inflammatory disease by conserva-
tive measures. I believe now that the ultimate
fate of a gonorrheal tube is operation. And I
say this in spite of the advent of the sulfa drugs.
Of course in the early cases of gonorrheal sal-
pingitis, sulfa is of definite value, and should be
used, but as a cure for a chronic tube I have my
doubts. We may carry the patient along for a
period, but let her indulge in excessives such as
drinking, heavy exercise, or intercourse, and you
are apt to have a flare-up. Penicillin may be the
answer, but at present the ultimate fate is opera-
tion.

I agree with Dr. Bendel that patients should
be thoroughly rested and prepared, and carried
along as far as possible before they finally come
to the table. There should never be an operation
in the face of any acute symptoms.

The essayist did not dwell on the surgical as-
pect of pelvic infection and in passing I want to
say that again I am becoming more radical. In
cases where hysterectomy is indicated I believe
that a complete hysterectomy removing the cer-
vix, is the best procedure. If the cervix is not
removed, it will be a source of trouble as long
as the patient lives. Complete hysterectomy in
competent hands carries only a slightly higher mor-
tality than supravaginal amputation, and the re-
sults certainly warrant the risk.

Dr. Bendel mentioned cul-de-sac abscesses. There
are two types, the gonorrheal, which to my mind
should not be drained. I say this on account of
its pathology. These cases are usually saculated
and only a pocket may be drained at a time. The
very nature of the infection is against surgical
procedure from below.

The type of abscess that lends itself best to
drainage, is the abscess following an abortion or
infections following a delivery. There the ab-
scess is usually retroperitoneal or' within the lay-
ers of the broad ligaments and points in the cul-
de-sac. Here drainage by posterior colpotomy is
successful.

Dr. Gordon Johnson (New Orleans) : I agree
with some of the remarks Dr. Dicks has made. In
the use of sulfa drugs in acute salpinigitis it de-

pends entirely upon the stage at which the drug
is given. That is, it depends on how long the pa-
tient has had acute salpingitis as to whether or not
you are going to get results. It has been defi-
nitely shown by Barrows and Labate, who reported
a series in which 70 per cent of the patients with
mild salpingitis and 66 per cent with moderate
involvement, where the attack was less than five
days in duration, that complete resolution of ad-
nexal masses took place. This is true because of
the fact that after five days there is destruction
of the tubal mucosa and formation of a purulent
exudate, and in such cases, the drug is of no value.
Sulfa drugs are of no value in chronic cases of
salpingitis or cervicitis.

I do not agree that the drug should be given
pr'eoperatively where chronic lesions of the cervix
are being handled surgically. It has definitely
been shown that they are of no value in chronic
infections of the generative tract. So if you see
patients early enough, definitely within five days,
you may be able to get somewhat close to the re-
sults Dr. Bendal stated, although I do not agree
on the percentage given of cured cases of sal-
pingitis or being completely relieved of symptoms.

As to the indications for operation in salpingi-
tis; I think it is accepted that there ar'e few indi-
cations in acute cases; even in those where there
is general peritonitis. I must disagree with Dr.
Bendel there — I believe he stated in some cases of
general peritonitis he advocates operation. We
treat conservatively by intravenous injection of
sulfa drugr. Indications in chronic infections are
mostly menstrual disturbances, severe dysmenor-
rhea, presence of large adnexal masses, cul-de-sac
abscess. I think cul-de-sac abscesses should be
drained, whether gonorrheal or non-specific in ori-
gin. The treatment we advocate in chronic is
salpingo-oophoritis radical. We have found at
Charity Hospital that conservative surgery is of
no value at all. Patients return from six months
to a year later with continuation of symptoms or
exacerbation of them. We advocate radical sur-
gery of tubes and ovaries and removal of the en-
tire uterus. I agree that the entire uterus should
be removed. I do not agree that it should be re-
moved by the occasional operator. In the hands
of the occasional operator or general surgeon, a
total hysterectomy carries a higher mortality. In
the hands of gynecologists it has been shown that
a total hysterectomy carries no higher mortality —
as a matter of fact in Charity Hospital where the
mortality for all our gynecologic surgery is 1 per
cent, total hysterectomy is even less than that.

Dr. Dicks stated that most cases will come to
operation; however, I think that mild cases that
do not cause a tremendous amount of symptoms
do not require operation. Where required, radi-
cal surgery should be done. Of course there is
no question that the use of the sulfonamide drugs
has decreased the number of patients requiring

256

SCH M idt — Brucellosis

operation. He stressed the number of patients
with extensive pelvic infections. On our service
I have noticed that in the last two years the num-
ber has decreased considerably and now we deal
mostly with fibroids.

Dr. Wm. L. Bendel (in closing) : I am glad that
I presented a subject that brings up a good deal
of disagreement. As far as I remember, from the
time I studied medicine, that has. been the case in
this type of cases. I remember when I worked un-
der Dr. Clark here there -were many tirades on
conservatism and as much disagreement as there
has been today. I still think Dr. Dicks’ case of
low percentage of cures is the result of mixed in-
fection and not gonorrheal infection per se. I want
to disagree with Dr. Johnson about conserving the
ovary. My experience has shown a lot of good
result in conservatism in ovarian tissue. One must
use his judgment, however, in the operative field.
I still think it wrong to de-sex a woman just as
much as any of you gentlemen would want to be
de-sexed.

Regarding sulfa drugs, Dr. Sellers mentioned
that the sulfa drugs are very important. I also
believe they are but believe we overdo the dosage
of these drugs. I believe the practitioner wants
to give too big doses. I believe you get as good
results with smaller doses as you do from over-
doses. These drugs certainly have a marked field
in the practice of gynecology.

GENERAL CONSIDERATIONS OF
BRUCELLOSIS*

HARRY J. SCHMIDT, M. D.

Convent, La.

For many years medical authors have
presented brucellosis as an acute infectious
disease of unusual severity and long dura-
tion. The classical description included the
typical recurrence of the hyperpyrexia
which they thought characterized the ill-
ness and because of which they termed the
condition undulant fever. The infection was
thought to be of rare occurrence and as
recently as 15 years ago these cases were
considered medical curiosities.

The prophecies of many early investiga-
tors who considered the disease a major
health problem are fully realized today.
The increased incidence of brucellosis is
more apparent than real and may be at-
tributed to more general recognition.

’'Read before the sixty-fourth annual meeting of
the Louisiana State Medical Society, April 24-26,
1944.

The disease is commonly thought to have
had its origin in Malta, from whence it de-
rived one of its many names. Hippocrates,
however, describes a febrile condition
which might well have been brucellosis. In
the biblical writings there is mentioned a
disease which caused abortions in women
and ewes. There are definite indications
that the infection has been widespread for
many years.

It was not the prevalence of acute bru-
cellosis among the natives of Malta that led
to the investigation and ultimate discovery
of the causative organism. The attention
of the British Medical Corps was attracted
to the high incidence of an acute febrile
condition among the soldiers shortly follow-
ing their arrival on the island. Today we
may attribute this to the fact that sus-
ceptible individuals entered an endemic
area of brucellosis. The discovery of the
disease in goats was purely accidental.
The native Maltese and their goats pre-
sented no more clinical evidence of infec-
tion than is seen today among the people
and fine dairy herds of many of our com-
munities.

The first case of brucellosis in this coun-
try was reported by Craig1 in 1905. Little
progress was made in the study of the dis-
ease until Evans2 in 1918 suggested that
Micrococcus melitensis, isolated by Bruce
from cases of undulant fever, was closely
related to bacillus abortus found by Bang
in contagious abortion in cattle. In 1924
Keefer3 reported the first case of undulant
fever in man to be caused by the Brucella
abortus.

During the decade following this report,
only the acute form of the disease was gen-
erally recognized. The agglutination test
was the usual procedure for diagnosis.

About ten years ago many reports ap-
peared describing the chronic form of the
disease in which there occurred a low grade
fever with a wide variety of symptoms.
Many laboratory data, containing reports
of the isolation of the organism, proved
conclusively that brucellosis does exist in
an obscure form and is definitely the cause

Schmidt — Brucellosis

257

of much morbidity among chronically ill
patients.

In more recent years, brucellosis has
been shown to cause active pathological
changes in every organ and tissue in the
body and consequently to mimic many other
diseases.

The high incidence of the infection in
cattle presents sufficient caus'e for the
widespread distribution of brucellosis. Con-
tagious abortion is known to have been
common for more than a century and a
i half. Thus it becomes apparent that a great
proportion of the population has been ex-
posed to the disease. Of sixteen samples of
milk selected at random in the city of New
Orleans five were found to contain Brucella
abortus 4. Although the series is small, the
percentage is startling.

The failure to recognize brucellosis may
be attributed to several factors, chief of
which are: the wide variation in the clini-
cal picture and the lack of adequate lab-
oratory procedures for diagnosis. Another
factor that adds to the confusion is that
the problems of diagnosis and treatment
vary in different localities depending upon
the extent and duration of the disease in
animals.

Due to the change of pathogenesis of the
Brucella organisms the disease has lost its
clinical identity and an original diagnosis is
rarely made.

It would be impractical to enumerate the
countless symptoms attributed to brucello-
sis. We may consider it sufficient to state
that since the organism has lost its particu-
lar affinity for any certain tissue and since
it has been recovered from practically all of
the tissues, then we may reasonably expect
any combination of symptoms compatible
to its involvement. To cloud further the
clinical picture, we must realize its role as
a focus of infection and the ill effects of its
endotoxins resulting in a varied syndrome
of functional disorders.

In endemic areas acute brucellosis is
rarely seen and is usually of short duration.
Many investigators believe that but few pa-
tients with chronic brucellosis have expe-

rienced previous acute febrile illnesses sug-
gestive of the acute infection. With the at-
tenuation of the organism and the resultant
change of the clinical picture, it would be
most difficult to distinguish the acute onset
from influenza or the many common febrile
conditions that usually terminate before
adequate laboratory data are obtained.

The symptom complex of chronic brucel-
losis varies to such an extent that clinical
diagnosis is practically impossible. Never-
theless there are certain characteristics of
obscure illnesses which might indicate the
presence of brucellosis.

Although fever is not a necessary symp-
tom, an adequate check of the temperature
is most essential. The majority of these
patients have some type of a low grade
fever though usually not conscious of it.
Norris and Landis5 state that “in order to
detect slight rises in the temperature the
thermometer should be left in the mouth
not less than 10 minutes.” The author
considers this the most important procedure
in the search for brucellosis. Invariably it
will be noted that the patient’s vague com-
plaints are associated with his low grade
fever. This fact is of definite significance
in the diagnosis of chronic brucellosis.

Another feature commonly noted in the
disease is the periodic recurrence of the
symptoms regardless of their nature. The
infection appears to have retained this
characteristic from its early acute form.

The appearance of unexplained fevers,
especially following pregnancy, surgical
procedures or acute illnesses strongly sug-
gest the possibility of brucellosis. This is
in accord with estimates that 10 per cent
of the people in endemic areas harbour the
organism. The development of the fever
merely indicates a temporary loss of immu-
nity.

The long duration of the vague com-
plaints without the presence of adequate
cause may lead one to suspect chronic bru-
cellosis. The usual features that distinguish
these cases are the presence of a low grade
fever, fatiguability and some type of pain
or discomfort.

258

Sc H M IDT — Brucellosis

The many complications that frequently
present themselves furnish important clues
for the diagnosis of the chronic infection.

With the complex symptom syndrome
and the notable absence of physical signs,
these patients are often considered to be
neurotics or neurasthenics. There is no
better precipitating factor for the develop-
ment of a neurosis than the uncomfortable
complaints and the mental depression asso-
ciated with a chronic Brucella infection.
The definition of neurasthenia adequately
describes chronic brucellosis.

The past history of obscured and undiag-
nosed fevers is often of value. All histories
of malaria should be looked upon with sus-
picion. Unexplained abortion is a suffi-
cient reason to investigate the possibility of
brucellosis. Obstinate urinary infections
may be of Brucella origin. Chronic chole-
cystitis is frequently noted in these pa-
tients. Arthritis without evident focus of
infection is a common finding. All obscure
illnesses and vague complaints should be
thoroughly checked for chronic brucellosis.

Physical examination of the patient is of
little value in diagnosis except for the elim-
ination of other possible conditions. With
the wide variation of the pathologic changes
and the vague clinical picture resulting
from the absorption of the endotoxins, it is
apparent that there are no pathognomonic
signs or symptoms.

The only laboratory procedure sufficient
for diagnosis is the isolation of the organ-
ism either by culture or guinea pig inocu-
lation. Reports show that postive cultures
have been obtained even in the most
chronic and obscure types of infection.
Some of these cases showed neither a posi-
tive skin reaction nor the presence of ag-
glutinins. I have seen such a case, yet un-
reported, in which Brucella abortus was re-
covered from the blood of a subnormal
child. Repeated tests during and following
the recurrent hyperpyrexia did not show
the development of agglutinins for any of
the three Brucella organisms. The skin re-
action was interpreted as being doubtful.
The blood specimen was taken one month
after the disappearance of the fever. No

specific therapy was given and there has
been no recurrence of the fever.

The organism has also been recovered
from the urine, feces, spinal fluid, joint
fluid, bile, breast milk, uterine discharges
and drainage from suppurative lesions.
Rositive cultures have been obtained from
surgical specimens including the tonsils,
teeth, gallbladder, appendix, lymph nodes,
oviducts and ovaries. At autopsy Brucella
organisms have been found in every tissue
and organ of the body including lesions of
the heart valves in bacterial endocarditis.

DIAGNOSTIC LAB OR A TOR Y PROCEDURES

Too much stress can not be placed upon
the importance of doing culture work in
brucellosis. This is apparent since the
other laboratory procedures are not ade-
quate for diagnosis in many instances. The
agglutination test is not a diagnostic pro-
cedure. The agglutinins are frequently
found in the acute cases and at times fol-
lowing an acute phase of a chronic infec-
tion. It is hardly to be expected to find the
presence of these antibodies in such a low
grade infection as chronic brucellosis. A
negative agglutination never excludes the
possibility of infection. In endemic areas
agglutinins in any titer, however low, are
of significance in the presence of suggestive
symptoms. The general misconception of
the agglutination test has definitely inter-
fered with the recognition of the disease.

The skin test alone is not sufficient for
diagnosis. The value is comparable with
that of the tuberculin. In endemic areas of
Bang’s disease one may expect a high inci-
dence of positive reactions.

The opsonophagocytic index is employed
only to determine the extent of immunity
present and is used in conjunction with the
skin test and agglutination test.’

The interpretation of these combined
procedures is of some value in arriving at
a diagnosis provided the laboratory data
conform with the clinical evidence of in-
fection as presented by the case.

It is my opinion that the true evaluation
of the complement fixation test will become
evident only when chronic brucellosis is
generally recognized.

Sch M IDT — Brucellosis

259

TREATMENT

The treatment of the disease has been a
subject of much controversy among stu-
dents of brucellosis. It is apparent that the
therapeutic needs vary in different locali-
ties depending upon the degree of chron-
icity attained by the infection.

The pathogenesis of acute brucellosis is
similar to that of typhoid fever and does
not require the use of a specific bacterin.
In the dangerously ill patient, the use of
immune serum and blood transfusions are
indicated as an emergency measure. Con-
tinued vaccine therapy following the acute
infection may prevent the latest recurrence
of the disease in a chronic form. Complex
problems are presented in the management
of the chronic infection. Contrary to the
opinion of many investigators, I have not
found vaccine therapy to be effective in
most cases. In a personal communication,
Charles Carpenter has expressed a similar
view. This difference of opinion is prob-
ably due to the varying degrees of patho-
genesis of the organisms as noted in the
clinical manifestations of the disease. In
those areas where the infections are of a
more subacute nature, vaccine therapy is
probably efficient.

As noted in many cases, the inadequacy
of vaccine therapy may be attributed to the
poor antigenic properties of the bacterin.
The eventual development of an effective
vaccine may come with further knowledge
of the clinical immunology of brucellosis.

In spite of the early optimistic reports,
the sulfonamides have proved to be of no
value as a specific agent. The only ration-
ale for the use of sulfaguanidine would be
in combating any local infection in the
bowel.

The various types of chemotherapy have
not generally been successful. Non-spe-
cific protein therapy has been of little
therapeutic aid. I have had no experience
with artificially produced fever or the toxic
filtrates.

In all cases of, chronic brucellosis, dili-
gent search must be made for any focus of
infection of the Brucella organisms.

The self limited duration of the acute in-
fection and the common recurrence of fever
after a period of years makes it difficult
to evaluate any type of treatment. The
many forms of therapy used suggest that
probably none is specific. Perhaps penicil-
lin may prove to be an effective agent.

It would be highly impractical to expect
every physician to become an enthusiastic
student of brucellosis; yet the complex sit-
uation must be realized and the possible
presence of brucellosis considered especially
in those obscure illnesses that present diag-
nostic problems.

It is just as difficult to make a clinical
diagnosis of chronic brucellosis as it is to
identify syphilis by its protean manifesta-
tions. At the most you may suspect it and
ultimately arrive at a diagnosis by means
of the combined clinical and laboratory
data with the elimination of other possible
conditions.

It is hoped that the increased recognition
of the disease may stimulate more research
which will eventually afford us a practical
diagnostic procedure and effective therapy.

The problems presented by brucellosis
today are similar to the circumstances that
existed years ago when it was suggested
that syphilis was of common occurrence.
The convincing evidence contained in the
literature suggests that the words of Sir
William Osier are equally appropriate for
brucellosis as they were for syphilis. The
brucellosis which we see but do not recog-
nize everywhere awaits diagnosis like syph-
ilis, so protean are its manifestations.

SUMMARY

1. Brucellosis, though unrecognized, has
probably been prevalent for many years.

2. The high incidence of the infection in
cattle presents sufficient cause for the
widespread distribution of brucellosis.

3. Laboratory data containing reports of
the isolation of the organism prove con-
clusively that brucellosis - does exist in an
obscure form and is definitely the cause of
much morbidity among chronically ill pa-
tients.

260

Sch midt — Brucellosis

4. Problems of diagnosis and treatment
vary in different localities depending upon
the degree of chronicity attained by the in-
fection.

5. Due to the change of pathogenesis of
the Brucella organisms the disease has lost
its clinical identity and an original diagno-
sis is rarely made.

6. With the wide variation of the pathol-
ogy and the vague clinical picture resulting
from the absorption of the endotoxins, it is
apparent that there are no pathognomonic
signs or symptoms.

7. The treatment of the disease has been
a subject of much controversy among stu-
dents of brucellosis.

8. The possible presence of brucellosis
should be considered in all obscure illnesses
that present diagnostic problems.

9. The disease may be suspected and ul-
timately diagnosed by means of the com-
bined clinical and laboratory data with the
elimination of other possible conditions.

REFERENCES

1. Craig, C'. F. : The symptomatology and diagnosis of
Malta fever with the report of additional eases, Interna-
tional Clinics, 15th. series, 4 :89, 190G.

2. Evans, A. C. : Further studies on bacterium abortus
and related bacteria, J. Infect. Dis., 22 :580. 191S.

3. Keefer, C. S. : Report of a case of Malta fever origi-
nating in Baltimore, Md., Bull. Johns Hopkins Hosp.,
35 :6, 1924.

4. Hauser, G. H. : Personal communication. March 1944.

0. Norris, G. W., and Landis, II. R. M. : Diseases of the

Chest and the Principles of Physical Diagnosis, Philadel-
phia, W. B. Saunders Co., 4th. ed., 1931. Pp. 376.

DISCUSSION

Dr. Robert C. Lowe: There is no need for me to
make any commendatory remarks about this pa-
per; I think Dr. Schmidt has spoken well for him-
self. I would like to point out though that his
work and interest in brucellosis is in accord with
what Simpson meant when writing on the subject.
He said that the number of chronic cases recog-
nized in a given community would depend upon
an individual being particularly interested in that
disease condition.

Brucellosis is primarily a disease of animals.
They form a reservoir of disease and man is inci-
dentally infected by casual or occupational contact
either direct or indirect. Presumably all individ-
uals are susceptible to the effects of these various
organisms. It is clearly evident that whether
clinical disease develops or not depends upon the
relative virulence of the organism and the strain
or type of the organism. It is probable that rela-
tive percentage in acute and chronic cases observed

in a given community depends upon the type of
organism and animal reservoir in that community.
This is particularly evident in the midwestern
states, where the suis variety in the hog population
gives rise to more acute infection and more exten-
sive epidemics of the infection when the pathway
from the animal reservoir to the human being be-
comes active.

Dr. Schmidt emphasized the difficulty in mak-
ing diagnosis in the chronic variety of the disease.
Simpson, in writing on this subject, instead of
going into a long involved classification by men-
tion of type of temperature, has merely divided
the cases into acute and chronic type. Harris, in
New York City, makes the remark that prior to
his specific interest in this disease he made no
diagnoses, but in a ten-year period during his
particular interest in it he made the diagnosis in
some four hundred instances. His practice was
in New York City and these patients were pre-
dominantly from rural areas, 70 per cent. Only
ten per cent of these individuals, with the diagno-
sis of brucellosis, showed the disease in an acute
form.

Dr. Schmidt’s remarks on the treatment are
quite valid and explain a lot of the difficulties
the medical profession is up against in the man-
agement of this condition. Taking into considera-
tion the difficulties in diagnosis and difficulties
in treatment after diagnosis is made, we might
be justified in looking further for the prevention
of the disease. While the medical profession has
its troubles with brucellosis in human beings,
those interested in the animal industry have by
far a much greater problem. It was net their in-
terest in the human form of the disease which led
to their attempts to eradicate the reservoir of in-
fection in cattle. In 1941 a survey of some 11
million cattle showed 38 per cent of the herds
and 8 per cent of all cattle tested infected. In
the diagnosis of brucellosis in cattle and hogs the
agglutination test is more consistently positive
than in man. In Louisiana some 38.9 per cent of
the herds were infected and 12.8 per cent of the
cattle in the herds were infected. In 1941 the
U. S. Bureau of Animal Industry reported that
at a cost of seven and a half million dollars there
were some 61,000 state accredited herds. By 1942
Huddleson reported 52 million animals had been
tested and over two million found to be reactors
and eliminated in the herds. As far as he was
able to observe this effort had had no effect upon
the incidence of human brucellosis.

This further emphasizes the need for adequate
pasteurization of all milk used as such or in the
manufacture of dairy products for human con-
sumption, in an effort to break the chain of in-
fection from the infected animals to man. Educa-
tion of the general public, as well as those who
may be exposed in the meat packing industry is

Schmidt — Brucellosis

261

a prerequisite to making- efforts at prevention
successful.

Dr. John M. Whitney (New Orleans) : I merely
would like to discuss one phase of this excellent
paper, I might say one phase which was not men-
tioned. That is the question of prevention. Of
course we are very much interested in the pre-
ventive side of this situation. We, for some time,
here in New Orleans, have had a very active
campaign to requix-e all milk consumed here to-
be pasteurized. At the px-esent time 95 per cent
of the milk consumed in the city is pasteurized
milk. The only sure way we know of to keep
from getting brucellosis is to drink properly pas-
teurized milk instead of raw milk. I do not think
we have been able to find a case on record of
infection traced to anything- else besides ingestion
of raw milk except rare instances where there
have been cases of meat handlers getting the dis-
ease.

I did not have occasion to talk to Dr. Schmidt or
to see his paper, but I am interested to know
the date of the examination of five samples of
milk he examined in New Orleans and found this
organism. We still find it often in raw milk; in
nearly every instance we can isolate the organ-
ism. Further than that we could and we do find
herds infected and we examine each quarter of
the udder of the cow and if infected have the
cow removed. It is difficult on the people pro-
ducing milk. There has been some agitation for
a state law in the next legislature to provide
relief for these people who have to slaughter good
dairy cattle in order to clean out their herd. Of
course in rural areas the pasteurization of milk
is hard to control or effect, but we know that
many times doctors can have their patients at
least boil their milk or take other precautions.

Dr. Allan Eustis (New Orleans) : I had the priv-
ilege of reporting the first case of Malta fever
occurring in Louisiana — about 1915 — so, that I
have naturally been much interested in the in-
creased incidence of this disease in the state.

This patient, a l-esident of Texas living on a
goat farm, was treated by me at the old Presby-
terian Hospital for ten days as a case of typhqid
fever. Agglutination tests were negative for ty-
phoid and pai’a-typhoid; there was no tympanites
and I was sti-uck by the fact that even when his
temperature was 106 he had no mental symptoms.
In mentioning this peculiar phenomenon to Dr.
Creighton Wellman, who was then Chief of the
Department of Tropical Medicine at Tulane Uni-
versity, he suggested that possibly the patient was
suffering from Malta fever. Agglutination of the
patient’s blood in Dr. Wellman’s laboratory gave
a positive reaction to micrococcus nxelitensis. The*
patient finally died after four weeks of a re-
mittent fever from 99 to 107 ; no postmortem was
performed. This case impressed upon me the lack

of subjective symptoms in the acute stage of bru-
cellosis, or undulant fever.

I have recently seen a case with positive agglu-
tination of brucellosis which I saw eight years
ago with high fever. There were no subjective
symptoms and all agglutination tests were nega-
tive ; she continued to run low fever and four
years later gave postive agglutination tests for
brucellosis and is still running temperature
eight years after the acute attack, but is in excel-
lent physical condition.

In emphasizing what Dr. Whitney has said about
pasteurizing milk, every housewife can pasteurize
her milk supply. During my rural practice I in-
structed my patients to heat the milk until a
scum formed on top, then to pour the milk into
bottles which had previously -been sterilized by
boiling in water. While this is not definitely sci-
entific, the milk is pasteurized.

Dr. J. H. Musser : You know they say that a
bad cold lasts thi’ee weeks if treated; and if un-
treated twenty-one days. To paraphrase, we
might say that acute brucellosis lasts for one year
when treated and persists for 365 days if not
ti-eated. That is not really a time statement but
does indicate definitely that while the actual inci-
dence of brucellosis, as far as the statistics gath-
ered throughout the state are concerned, may seem
small, actually the morbidity is sometimes tremen-
dously prolonged and causes invalidism over
months and sometimes, as Dr. Eustis said, for
years. I still believe that Dr. Schmidt has some-
thing very real here and a tremendous amount of
credit belongs to him for the studies he has made
on the incidence of chronic brucellosis. From his
observations and from his records apparently what
I have said about brucellosis being a relatively
rare disease today is erroneous. In his practice
in his opinion, chronic brucellosis is the most fre-
quent disorder seen and expresses itself, as brought
out by him, in innumerable ways. I think Dr.
Schmidt, a man engaged in the complexities of a
rural practice, deserves a tremendous amount of
credit for his work on this disease. I hope the
doctors located in the country districts will con-
sider the possibility that patients with arthritis,
with anemia, with fatiguability, or what not, may
have chronic brucellosis.

Dr. Harry J. Schmidt (in conclusion) : Dr. Lowe
brought out an important phase which I did not
cover; that is, the infection in the cow. I believe
that this is the key to the whole situation. Most
of us, especially those in the city, probably con-
sider milk as coming from a bottle or a can. I
believe that the cow plays an important role in
the attenuation of the organism and consequently
is largely responsible for altering the disease in
man. The infection has undergone the same
changes in the cow as in the human. In more
recent years, there is a marked diminution in the
diagnostic signs in cattle.

262

Katz — Peptic Ulcer

Partly due to our activities in St. James Parish,
the U. S. Department of Agriculture made a sur-
vey among the cattle. It was consistently noted
that only the finest stock were the positive reac-
tors. In the best dairy herd of the Parish, the
incidence of the disease was 60 per cent and the
animals found to be positive reactors were of the
best stock of the herd. In the case of family cows,
the finest cow in the yard was usually the posi-
tive reactor.

This brings up the question of the value of the
agglutination test in cattle. It is apparent that
only the better cattle are able to develop anti-
bodies against the disease. The infected non-
reactors are not able to develop immunity. The
role played by the cow becomes apparent when
we observe the relative pathogenesis of the Bru-
cella organisms. We know that B. abortus is not
as virulent as B. melitensis except in those areas
where goat milk is commonly used. I do not
believe that the agglutination test is sufficient
for the diagnosis of Bang’s disease in cattle.

There has been infection in the fine herd at
L. S. U. for years. At one time they separated
the cattle into clean and infected herds. Later it
was difficult to distinguish the herds.

The only prevention of brucellosis is by the
use of boiled or pasteurized milk. The importance
of this was stressed by Dr. Whitney. One can
not rely upon the fact that the cow has been
checked and found to be a negative reactor. I
critcize the Department of Agriculture in this
respect. Although they do not tell people that it
is safe to drink the raw milk, they imply as much.
All owners should be warned that though their
cattle are non-reactors, the milk may harbour the
organism.

Dr. Eustis mentioned the fact that there are
usually no symptoms. In the acute type of infec-
tion, there is only fever, the duration of which
varies to a great extent. In a previous paper, I
reported a case of one day’s duration; the agglu-
tination was positive in a high titer and the pa-
tient was known to have been drinking infected
milk. He has had no fever or symptoms for a
year and a half and may be considered as having-
made an uneventful recovery.

Dr. Musser brought out the point about dura-
tion. There are no limits to the duration. I have
one case of the chronic type that gives a history
of a probable infection for the past twenty years.
The case was clinically diagnosed and later veri-
fied by a positive agglutination in a low dilution.
He has a low grade fever with a maximum tem-
perature of 100. The source of milk was from
a herd known to be heavily infected with Bang’s
disease. At the onset, the acute illness was thought
to be malaria.

PEPTIC ULCER:

PSYCHOSOMATIC AND MEDICAL ASPECTS*

ROBERT A. KATZ, M. D.

New Orleans

Statistics accumulated from all parts of
the world reveal an alarming increase in the
incidence of peptic ulcer in both civilian and
military practice. The British have re-
ported an incidence of 35 to 55 per cent of
ulcer in their gastrointestinal cases.1 Is
this increase more apparent than real?
There is some evidence that it is.

Careful history taking reveals that from
80 to 90 per cent of peptic ulcers diagnosed
in the army existed prior to enlistment.2
The basic constitutional type of person
having peptic ulcer, when exposed to the
extreme emotional shocks connected with
modern warfare and the irregularity of diet
and rest, becomes a good candidate for the
recurrence of ulcer symptoms. It is true
that the individual patients may not have
been conscious of having a peptic ulcer be-
fore the actual diagnosis was made by the
military physicians. In civilian life this
person may have accepted the symptoms of
periodic pain as a simple digestive upset
and have procrastinated in seeking medical
advice, allowing nature to effect the cure.
However, when in the army the situation
is changed. He knows that he cannot fall
out of step and live according to his own
tempo. At this stage he reports to his med-
ical officer, and is consequently djagnqsed
much earlier than in civilian life.

The purpose of this paper is to seek out
a reason for the poor results achieved by
the present accepted standards of medical
treatment of peptic ulcer.

As a basis for this study a review of 100
cases of gastro-duodenal ulcers was made,
with the object of determining the limita-
tions of our present means of therapy. This
study revealed an exceptionally high rate
of recurrence and complications, much
higher than we would ordinarily expect

*Read before the sixty-fifth annual meeting of
the Louisiana State Medical Society, New Orleans,
April 24-26, 1944.

Katz — Peptic Ulcer

263

from a method of treatment that is so uni-
versally accepted.

The reason for our failure in achieving
better results is becoming apparent to those
of us who are becoming impressed with the
psychosomatic components in peptic ulcer.
Pioneers who early observed the effects of
the emotions on physiologic changes are
well known to us.

Certainly the very fundamental observa-
tions of Beaumont 119 years ago on the
Canadian voyageur, Alexis St. Martin, is of
note. It will be remembered that St. Martin
suffered an injury to the stomach which
was repaired by Beaumont, but fortunately
left a gastric fistula. Beaumont kept St.
Martin in his home for ten years, making-
some of the earliest direct observations on
gastric secretion. Among other things, he:;
observed that changes in emotional states
could influence the quality and flow of the
gastric juice.

Pavlow,4 in his experiments on dogs
seventy years later, gave us with the false
gastric pouch a refined method for the fur-
ther study of gastric secretion. Bidder and
Schmidt5 made the first observations on
psychic secretion, a method later used by
Pavlow in his sham feedings. In 1898
Cannon,0 with the aid of the x-ray, began
his studies on the effect of the emotions on
gastric physiology.

In view of the foregoing, it is rather sur-
prising that so little weight has been given
to the role of the psychosomatic or emo-
tional disturbances in the diagnosis, pro-
phylaxis and treatment of peptic ulcer.

Strictly speaking, psychosomatic medi-
cine is that part of medicine which is con-
cerned with an appraisal of both the phys-
ical and emotional mechanisms involved in
the disease process. As Dunbar so aptly
put it, “the terms psychic and somatic rep-
resent two angles of observation from
which the organismal unit should be stud-
ied, two pictures which should then be
viewed stereoscopically.”

PSYCHOSOMATIC THEORY OF CAUSATION OF ULCER

Simply stated, nervous or psychic de-
rangements affect the hypothalamus or di-

encephalon. The disturbance moves over
sympathetic and parasympathetic pathways
to reach and disturb the normal function
of the stomach and intestine.

The hypothalamus appears to be the con-
trolling center for processes which reside
in the subconscious and without voluntary
control. This center controls the function
of digestion and secretion of acid in the
stomach, also the process of absorption.
Experimentally, electrical stimulation of
this center, for example in the dog, may
produce a condition of spasm plus an in-
creased secretion of gastric juice. Further
experimental injury at the base of the dog’s
brain leads to congestion and hemorrhage
of the stomach.

To apply this sequence of events to a
typical ulcer patient: His brain and emo-
tional centers have been disturbed by con-
stant anxiety. These nervous strains af-
fect the higher brain centers ; subsequently,
through the involuntary pathways, there is
an increase in spasm and secretion in the
stomach. The stomach will react by ische-
mia, congestion, hemorrhage and finally
ulcer. In other words, it may be assumed
that in the usual stresses of life, impulses
originating in the cortical tissue of the
brain may activate the autonomic centers
in the diencephalon and accordingly be re-
sponsible for the gastric activity associated
with peptic ulcer.

Long ago Cushing7 discovered that me-
chanical irritation of the hypothalamus,
known as the emotional center, may cause
alteration of motility, gastric secretion and
blood supply, leading in some cases to ulcer
formation. In other words, it is reasonable
to assume that these changes may also be
brought about by cortical stimulation from
severe emotional stimuli.

Peptic ulcer appears to be more and more
a civilization disorder. It is rather rare in
those parts of the world where stresses,
strains and tensions are absent.

The triad that easily identifies the psy-
chosomatic pattern of the ulcer patient is
the one characterized by hypersensitivity,
hyperirritability and hyperactivity8. All
physicians coming in contact with gastro-

264

Katz — Peptic Ulcer

intestinal patients, especially ulcer, know
the type referred to. The personality of
peptic ulcer patients is characterized by a
manner of tenseness which is accompanied
by an unusual drive. As a person, he is
often a true individualist, given to execut-
ing his duties in a very painstaking and me-
ticulous manner. His hypersensitivity is
often masked, as very frequently there is
no external manifestation of his mental
agitation.

Many of us who see a considerable num-
ber of ulcer patients have been struck with
the relationship of the adolescent changes
to the beginning of ulcer symptomatology.
It is the thought of many that the transi-
tion from childhood to adolescence, which is
typified by profound physiologic and emo-
tional changes, is very frequently also the
beginning of the changes in gastrointestinal
physiology and symptomatology which may
develop into gastric distress or ulcer.

Careful delving into the background of
peptic ulcer patients will reveal the begin-
ning of this gastric distress in the adoles-
cent period. At this time they complained
of vague “stomach pains,” diarrhea, severe
constipation (spastic) and flatulence. In
those who were studied by x-ray, little was
found except positive evidence of spasm in
all parts of gastrointestinal tract studied.
Gastric analysis showed hyperacidity.
Bockus9 has labeled a group with the same
picture as pseudo-ulcer or pyloro-duodenal
irritability. It may be that very careful
follow-up studies will reveal that this syn-
drome is the intermediate link in the pro-
duction of peptic ulcer.

MECHANISM OF PAIN IN ULCER

It is the belief of many gastroenterolo-
gists that the pain in peptic ulcer is a by-
product of two processes, spasm and hyper-
acidity. Excessive emotional reactions may
be the source of inducing these abnormal
physiologic states through the mediation of
the centers in the hypothalamus.

GENESIS OF PEPTIC ULCER

A recent experimental study by Wolf and
Wolff10 on the genesis of peptic ulcer in
man has lent further proof to the psychoso-
matic concept. These men working at Cor-

nell University made a group of studies on
a man of 56 who had had an occluded eso-
phagus since the age of nine, and had fed
himself ever since through a gastric fistula,
surgically produced. Through the stoma, a
collar of gastric mucosa was protruded on
the abdominal wall. This man was em-
ployed as a helper in the laboratory of the
doctors. The patient was described as be-
ing in excellent health, and as being a small,
wiry man who was characterized as being
shy, sensitive, proud, stubborn and slightly
suspicious.

The object of their experiment was to re-
produce by emotional stimuli the three ef-
fects that will produce ulcers in animals;
namely, continuous acceleration of acid by
histamine, the maintenance of hyperacidity
by constant vagus stimulation and. finally,
the same result by continuous sham feed-
ings.

As is well known, not one of the three
stimuli referred to above is operative in
human beings with ulcer.

The purpose of the study was to discover
a stimulus in daily life which wrould result
in a continuous and sustained acceleration
of acid. Such a stimulus in certain con-
stitutional types consisted in the daily emo-
tional reactions which induced observable
degrees of hypersecretion comparable to
that which resulted from prolonged hista-
mine absorption, vagus stimulation and
sham feedings.

The observations on this patient are a
rather clear demonstration of how well
they conform to the psychosomatic concept
of peptic ulcer genesis.

The conclusions of Wolf and Wolff are
succinctly stated as follows:

(1) Emotions such as fear and sadness,
which involved a feeling of withdrawal,
were accompanied by pallor of the gastric
mucosa and by inhibition of acid secretion
and contractions.

(2) Emotional conflict involving hostil-
ity, anxiety and resentment were accom-
panied by accelerated acid secretion, hyper-
motility, hyperemia and engorgement of
the gastric mucosa, resembling “hypertro-

Katz — Peptic Ulcer

265

phic gastritis.” This series of events was
much more commonly observed in the pa-
tient. It was associated with gastrointes-
tinal complaints of the nature of heartburn
and abdominal pain.

(3) Intense sustained anxiety, hostility
and resentment were found to be accom-
panied by severe and prolonged engorge-
ment, hypermotility and hypersecretion in
the stomach. In this state, mucosal ero-
sions and hemorrhages were readily in-
duced, even by the most trifling traumas,
and frequently bleeding points appeared
spontaneously as a result of vigorous con-
traction of the stomach wall.

(4) Contact of acid gastric juice with
such a small eroded surface in the mucous
membrane resulted in accelerated secretion
of acid and further engorgement of the
whole mucosa. Prolonged exposure of such
a lesion to acid gastric juice resulted in the
formation of chronic ulcer.

(5) The lining of the stomach was
found to be protected from its secretions by
an efficient insulating layer of mucous, en-
abling most of the small erosions to heal
promptly in a few hours. Lack of such a
protective mechanism in the duodenal cap
may explain the higher incidence of chronic
ulceration in this region.

(6) It appears likely, then, that the
chain of events which begins with anxiety
and conflict and their associated overactiv-
ity of the stomach and ends with hemor-
rhage or perforation is that which is in-
volved in the natural history of peptic ulcer
in human beings.

DIAGNOSIS AND PROPHYLAXIS OF PEPTIC UCLER

Frankly stated, the diagnostic acumen in
recognizing peptic ulcer is excellent. Few
physicians, indeed, have to be reminded of
the rhythmic recurrence of pain and relief
of pain by food in duodenal ulcer. There is
no extragastroduodenal organic disease
which mimics this classical syndrome. It is
not, then, our failure to recognize the
disease that accounts for the increasing in-
cidence of the disease.

The lack of success in handling the prob-
lem can be accounted for by our neglect
of the personal factor from the time the

patient first presents himself. Anyone
handling peptic ulcer patients should pursue
with equal diligence and interest the inquiry
into the psychosomatic pattern of the pa-
tient, just as carefully as he has determined
the pathological pattern of the mucous
membrane as revealed by x-ray.

The late William Mayo once said that
every physician in every specialty should
be able and willing to diagnose and treat
the neuroses that belong in his field — a re-
markable insight into the importance he
attached to the emotional components of
disease.

It is not enough to send the patient to
the x-ray laboratory, order a gastric analy-
sis, or determine the occult blood in the
feces to diagnose peptic ulcer. In the past
a summary of the abqve was considered
enough and a prescription for an antacid
and a diet completed the investigation.

As has been said before, the patient with
peptic ulcer, in addition to having an an-
atomic defect, usually also has an emotional
defect which, unless searched out by a care-
ful history of his psychosomatic manifes-
tations, will result in a poor medical re-
covery. It is obvious that emotional up-
heavals can prevent healing and this no
doubt accounts for the so-called medical
failures which result in calling the surgeon,
who forthwith does a gastro-enterostomy
and produces a surgical failure if our pa-
tient develops a jejunal ulcer.

A minimal psychosomatic history should
include at least three points, as related by
Dunbar r11

(1) A picture of the patient’s life in
which his major environmental stresses are
outlined, together with his psychologic and
physiologic reaction to them.

(2) A picture of the patient’s character-
istic reaction patterns in terms of the en-
vironmental and emotional situations to
which he has adjusted with ease or with
difficulty, again in relation to illness his-
tory.

(3) The topics which he tends to avoid
and misrepresent, and the topics that are
accompanied by an increase or decrease in

266

Katz — Peptic Ulcer

his skeletal response and temporary in-
crease or relief of his symptoms.

The import of the above is that it made
apparent the relationship of the fear, anx-
iety or conflict to the symptoms.

The data obtained from a careful psycho-
somatic history will quickly make apparent
the important factors which we should
keep in mind to encourage the prophylaxis
of peptic ulcer. First, we must recognize
that ulcer develops in a certain constitu-
tional type, characterized by definite phys-
iologic and psychologic pattern. These peo-
ple are represented by a class exhibiting the
triad of hypersensitivity, hyperirritability,
and hyperactivity. Their life is full of
tension, anxiety, fear and conflict. The
autonomic nervous system responds in these
individuals in a way to make the stomach
susceptible to the influences under which
ulcer formation is possible.

Many patients in whom no anatomic de-
fect is found, such as the patients with
pyloro-duodenal irritability described by
Bockus, probably represent a potential
peptic ulcer group and may well be the con-
necting link, as brought out by him. These
patients, as has been mentioned, exhibit
practically the complete duodenal ulcer
symptomatology. This group should be
carefully managed, as they are generally a
very young group. They should be investi-
gated carefully as outlined above and defi-
nite recommendations should be made to
remove them as far as possible from any
background of tension, anxiety or conflict.
It is well to explain the physiologic mech-
anisms to the patient, because without an
adequate understanding on his part failure
is predestined.

Other extraneous influences on the de-
velopment and recurrence of ulcer worth
mentioning are the avoidance of tobacco
and alcohol and, finally, the avoidance of
fear and anger, plus regular intervals be-
tween feedings.

M ED I CAL XU EAT M K XT

The treatment of peptic ulcer today may
well set the example of how the psychoso-
matic approach can be applied to a major
clinical entity. With the increasing evi-

dence from physiologic studies on the effect
of the emotions on gastric activity, a real
beginning is now being made in directing
the treatment so as to overcome the failures
of the past. No longer is it right to take a
brief history, do a gastric analysis and get
a roentgen study to complete the diagnosis
of ulcer. Each patient should be studied
carefully as to his emotional status and its
relationship to his environment.

The patient who has an ulcer should be
informed that he has a chronic disease with
which he can live comfortably for a life-
time, if he lives according to a rational
routine. Perhaps the failures we have had
have been due primarily to the lack of stress
on this one point. The patient frequently
looked at his ulcer as a wound of his bowel
— he kept it under watchful care until it
healed and then promptly forgot about it.
All too often a peptic ulcer patient has
stayed under a careful regimen for from
two to five months, later to throw all cau-
tion to the winds and have a recurrence.

The patient should be made to under-
stand that his physician is interested in
taking the responsibility of checking him
over from time to time — much the same as
a diabetic patient remains under the disci-
pline of a physician indefinitely.

It is far better to be careful and exact-
ing in advising the patient about his disease
in the begining of treatment rather than
doing the same after he has had a recur-
rence. At this later stage it is much harder,
because the patient is frequently discour-
aged and has become extremely stomach
conscious. He is likely to take the attitude
that he is an invalid for life and that at
any time he is likely to have a serious re-
currence of complication.

It is well to look into the patient’s rela-
tionship to his home environment. Weiss12
has made the statement that “men with
functional disturbances of the stomach have
a very high incidence of marital difficul-
ties.” Certainly it is true that marital in-
compatibility may account for a great part
of the emotional instability. If this is the
case, it is obvious that a removal from the
environment is the very first objective of

Katz — Peptic Ulcer

267

treatment. The patient should be hospital-
ized and be carefully conditioned to the ne-
cessity of the change.

The advantage of hospitalization in the
treatment of ulcer cannot be questioned. It
is by far the most efficient way to achieve
a therapeutic result from the standpoint of
actual medical therapeutics, and also as a
means of keeping the patient under a happy
environmental surrounding. Too often the
tense responsibilities of business or a job
cannot be eliminated from the patient’s
consciousness in any other way than by
either hospitalization or a removal to a dif-
ferent scene.

Occasionally it may be profitable to talk
to the patient’s employer, especially if the
latter manifests an interest. It may be
possible to work out a plan to do away with
some of the sources of irritation and there-
fore make it possible for a better adjust-
ment to the disease.

Besides the actual emotional factors,
there are at least two commonplace popular
habits that do not bide well with the ulcer
patient — smoking and excessive drinking.

The tremendous increase in smoking
seems to run directly proportional to the
increase in ulcer cases. During the first
World War cigarette consumption doubled.
Consumption today is nearly eight times
what it was in 1919. Bastido reported that
there were 123 billion cigarettes manufac-
tured in 1930.

As is well known, ulcer is primarily
found in the individual with a rather un-
stable autonomic nervous system. Nicotine
is a drug that acts rather selectively on this
system. Tobacco may also affect the cir-
culation, introducing another factor and,
finally, it very definitely is a cause of
hyper-secretion of acid.13 Individuals suf-
fering from ulcer become aware of their
symptoms with a jolt whenever they over-
indulge in cigarettes. There are many of
us who have seen the recurrence of symp-
toms and often hemorrhage after the re-
sumption of heavy smoking.

It is a curious fact that the ulcer patient
will generally admit that he feels better
after giving up smoking. Of course, it may

be argued that excessive smoking is only a
symptom of the tense and emotionally dis-
traught person. When he cuts out his cig-
arettes it is a pretty good indication that
he is learning a little of the art of relaxa-
tion, and this should be brought home to
him.

It is generally conceded that alcohol is a
gastric irritant and should accordingly be
interdicted during the active treatment of
peptic ulcer. Alcohol, per se, may not
cause an ulcer, but clinical experience has
given ample proof that it may be the factor
causing a recurrence of symptoms.

HOSPITAL VERSUS AMBULATORY TREATMENT
OF PEPTIC ULCER

An active case of peptic ulcer is best
treated in the hospital, under the routine of
small feedings of milk and cream, usually
every hour. Adequate attention to protein
and vitamin needs must be met. This can
be provided by the administration of any of
the powdered vitamin mixtures with the
feedings, for example, Cal C Tose, two tea-
spoons four times daily. An adequate in-
take of protein can be provided by a similar
high protein supplement to the milk. Fur-
ther protein may be administered in the
form of U. S. P. gelatine to the amount of
half an ounce with grape juice three times
daily. It has been my plan to give each pa-
tient at least 300 mg. of ascorbic acid daily,
during the first two weeks, administered in
100 mg. doses three times dairy.

The rationale of small bland regular feed-
ings, increasing in amounts weekly, is still
the sheet anchor of ulcer therapy.

Of the antacid preparations, it is my plan
to make use of either the aluminum or the
magnesia trisilicate preparations. The role
of hyperacidity in the perpetuation of ulcer
symptomatology appears well founded. Ade-
quate neutralization can usually be effected
with either of these preparations in the
usual dose of one to two teaspoons in a third
of a glass of water every hour.

Recently I14 have completed a two year
study with a colloidal preparation of the
hydroxides of iron and aluminum (feralu-
mina) , in the proportion of 3 per cent alum-
inum and 1 *4 per cent iron hydroxide. The

268

Katz — Peptic Ulcer

iron hydroxide is non-irritating and has
the further virtue of supplying iron to those
cases of peptic ulcer where there has been
considerable oozing, leading to an iron de-
ficiency state. A dose of half a teaspoon of
this preparation every hour has worked out
very well.

Occasionally the aluminum compounds
lead to troublesome constipation. This can
be easily remedied by the simultaneous ad-
ministration of milk of magnesia in two to
three dram doses two or three times, in com-
bination with the aluminum antacid. Very
rarely is it necessary to administer an anti-
spasmodic, but if it should be, an appropri-
ate dose for the patient of atropine or bella-
donna may be administered.

In these days of acute shortage of hospital
beds it is necessary to treat a certain num-
ber of patients at home. I find it very sat-
isfactory to supply the patient with a type-
written schedule of feedings and medica-
tions. It is rather surprising to see the
good results even in home cases, providing
the patient’s wife or nurse has the proper
attitude to the program. It is well to have
a specimen of stool sent to the office at least
once a week.

The ambulatory treatment of peptic ulcer
is usually unsatisfactory, but in these days
it frequently must be done because of the
particular essentialness of the worker to his
job. As related above, an adequate appraisal
of the patient’s individual status must be
made. In this patient it is very important
to insist upon regularity in feedings, much
the same as if the patient were in the hos-
pital or at home. The feedings should be
taken on the hour. The patient must pro-
cure one or two thermos bottles, mix his
feedings at home, and then proceed to fol-
low the schedule of hourly feedings. To
neutralize the acidity, an antacid prepara-
tion in the form of tablets for convenience
may be given.

While it is admitted that ambulatory
treatment does not compare in effective-
ness with the rest treatment, it is never-
theless a necessity of the times and is sur-
prisingly efficient in many cases.

The basic problem in all ulcer treatment
is one of treating both the patient and his
ulcer as one. Too often we have heard
that the ulcer is intractable and operation
is the only alternative. With a keener in-
sight into psychosomatic medicine it be-
comes apparent that both the ulcer and the
patient can be made tractable — it requires
only that we make use of the fundamental
observations made 119 years ago by Beau-
mont on the effect of the emotions on gas-
tric physiology.

SUMMARY

Psychosomatic medicine is that part of
medicine which is concerned with an ap-
praisal of both the physical and emotional
mechanism involved in the disease process.

Statistics accumulated from all parts of
the world show an alarming increase in
peptic ulcer.

The neglect of the psychosomatic com-
ponents of peptic ulcer may be responsible
for the high incidence.

Fundamental observations on relation-
ship of emotions to gastric activity first
made by Beaumont 119 years ago, followed
later by Pavlow, Cannon, Cushing, and
Wolf.

Psychosomatic theory of causation of ul-
cer concerns effect of emotions on hypo-
thalamus and subsequent spreading of im-
pulse over autonomic pathways to reach
and disturb normal function of stomach and
intestine.

Personality of peptic ulcer patient char-
acterized by hypersensitivity, hyperirrita-
bility and hyperactivity.

Wolf and Wolff produced peptic ulcer in
a patient with gastric fistula by stimuli cal-
culated to act on emotions of subject.

The basic elements of a psychosomatic
history have been stated.

Medical treatment of peptic ulcer has
been reviewed from the standpoint of actual
procedures and medications.

The psychosomatic approach to the prob-
lem of peptic ulcer offers a method of diag-
nosis and treatment that is based on both
physiologic and psychologic principles and
offers the physician a further aid to an un-
realized therapeutic goal.

Katz — Peptic Ulcer

269

REFERENCES

1. Hutchinson, J. II. : The incidence ol: dyspepsia in a
military hospital, Brit. Med. J., 2 :7S, 1941.

2. Crohn, B. B. : iFeptic ulcer in wartime, editorial,

Am. J. Digest Dis., 8 :359, 1941.

3. Beaumont, William : Experiments and Observations

on Gastric Juice and the Physiology of Digestion, Plaits-
burg, 1833.

4. Pavlow, I. P. : The Work of the Digestive Glands,

Trans, by W. II. Thompson, London, 1910.

5. Bidder, F„ and Schmidt, C. : (The Psychic Secre-
tion of Gastric Juice) Die Verdauungssiifte und der Stoff-
wechsel. eine Physiologisch-chemische Untersuchung. Mi-
ttau, 1852.

6. Cannon, W. B. : The influence of emotional states

on the function of the alimentary canal, Am. J. Med. Sci.,
137 :480, 1909.

7. Cushing, II. : Peptic ulcers and the interbrain, Surg.

Gynec. & Obst., 55:1, 1932.

8. Morrison, S., and Feldman, M. : Psychosomatic cor-
relations of duodenal ulcer, J. A. M. A., 120 :738, 1942.

9. Bockus, H. : Gastro-Enterology, Philadelphia, W. B.

Saunders Co. 1943.

10. Wolf. S.t and Wolff, H. G. : Genesis of peptic ulcer
in man. J. A. M. A., 120:670, 1942.

11. Dunbar, F. : Psychosomatic Diagnosis, New York,

Paul B. Hoeber, 1943.

12. 'Weiss, E., and English, O. S. : Psychosomatic Medi-
cine, Philadelphia, W. B. Saunders Co., 1943.

13. Rosenblum, IT.: Cigarette smoking:, its effect on

volume and acidity of gastric juice, with particular refer-
ence to duodenal ulcer, Calif. & West. Med., 49 :191, 1938.

14. Katz, Robert A. : The use of the hydroxide of iron

in peptic ulcer. (To be published).

DISCUSSION

Dr. A. A. Herold (Shreveport) : In the brief

period allowed, Dr. Katz has given us an excel-
lent resume especially dealing with the psychic
factor and treatment of the psychosomatic aspect
of peptic ulcer. There were a few things not
brought out as the paper was also to cover the
medical ideas. He did mention rest and we know
that rest is very important in treatment of acute
peptic ulcer unless it causes too much irritation.

Important also is administration of vitamin C
with ascorbic acid and milk and cream. That is an
important factor in the treatment of cases from
the medical standpoint. With a restricted diet it
is necessary to put the patient on ascorbic acid
because if not given scurvy may result. I quote
from Dr. T. Grier Miller of Philadelphia: “The
psychogenic factor in the etiology of peptic ulcer,
as in many other affections of the digestive tract,
is receiving a great deal of attention at the present
time, due in part perhaps to the emphasis that is
now being placed on psychosomatic medicine in
general. It has been claimed, for instance, that
disturbance of the emotional centers in the brain,
acting through the hypothalamus and the auto-
nomic nervous system, set up motor and secretory
changes in the stomach, and also that by the same
paths they sensitize its nervous mechanism and so
lead to vasomotor reactions with ischemia (believed
by some to be an important factor in the produc-
tion of ulcerations). Irrespective of the signifi-
cance of such a theory as to the pathogenesis of

ulcer, it is certainly true, with regard to its man-
agement, that when the ulcer patient puts himself
in the hands of a competent, sympathetic and un-
derstanding physician, transfers to him his person-
al concern about his condition and cooperates with
him in every detail of the management, the first
great step toward recovery has been taken.

“The ideal relationship between the doctor and
his peptic ulcer patient does not develop spontane-
ously, although some physicians, by virtue of their
personality, their reputation for competence and
their ability quickly to understand and to adjust
themselves to the patient’s mental and emotional
reactions, are able almost at once to secure his
complete confidence and cooperation. More
often this cordial and beneficial relationship
develops only as a result of a conscious and meticu-
lous effort on the part of the physician. That in-
volves at least a careful, painstaking study of the
case and the institution as promptly as possible of
some form of management, however simple that
may be. The mere fact that the patient is made
to feel from the beginning that his physician is
interested, not only in him but also in his disease,
and that his case is receiving personal study and
treatment, is most important psychologically, and
this is doubtless the explanation for the success of
many varieties of therapy, whether rational or not
and whether prescribed by a physician or a cultist.

“An exhaustive investigation of the patient’s
disease condition, therefore, may be regarded not
only as essential to the physician in order that he
may make a correct diagnosis and outline an in-
telligent program of therapy, but also as an actual
part of the management of the case. It should
include, besides a carefully elicited and detailed ac-
count of all the complaints, whether strictly gastro-
intestinal or not, and a meticulous examination of
the entire body, at least the following special
studies: a gastric analysis, a complete roentgeno-
logic study of the digestive tract, an inspection of
the feces, especially for blood, and sometimes, if
the lesion is in the stomach, a gastroscopic investi-
gation. If also, at the first visit, the patient is
put on some simple dietary program, often only
frequent feedings of a nonirritating diet, his thor-
ough cooperation usually will have been secured by
the time the diagnostic procedures have been com-
pleted, and indeed his symptoms may, even before
that time, have entirely disappeared. Even so, how-
ever, although no additional specific therapy may
be required, the patient should, at least for psy-
chological reasons, be kept under general observa-
tion and re-examined by a roentgenologist from
time to time until all objective signs of activity
have disappeared.”

This is in a way only stressing points brought
out by Dr. Katz and also refers to a talk by Dr.
Watters yesterday in which he emphasized the re-
lationship so necessary between the physician and
the patient.

270

Lane — Ruptured Intervertebral Disks

In conclusion, I would like to state that whether
peptic ulcer is treated medically or surgically and
relieved, it can not be considered cured until other
factors, as mentioned, are taken into consideration.

Dr. Donovan C. Browne (New Orleans) : There
is only one point in Dr. Katz’s excellent presenta-
tion I wish to comment upon. The present popu-
lar trend is to over-stress the psychosomatic, not
only in the etiology of peptic ulceration, but like-
wise in its management. That this may play a
role in the susceptible case is unquestioned and cer-
tainly the work of Wolf and Wolff remains a clas-
sic, but do not allow yourselves to become too en-
thusiastic. Bear in mind that an organic lesion
exists which carries with it the possibility of grave
and disabling complications, and that management
of the peptic ulcer case involves first the care of
the immediate ulceration, and second teaching the
ulcer patient to live with himself.

Dr. Katz is certainly to be congratulated for his
presentation.

Dr. Robert A. Katz (in closing) : The medical

phase of the treatment of peptic ulcer is taken up
in the manuscript and was not emphasized here;
however the one thing I can say is that I am in
complete agreement with Dr. Browne and Dr.
Herold.

The thing I want to emphasize is that by speak-
ing of psychosomatic medicine we just revert
to the old idea of the family physician where he
understood the problem and made the patient live
happily with his disease. If peptic ulcer is under-
stood to be a chronic disease the patient will get
along with it. If he thinks the wound in the bowel
is healed you will have him back for a patient over
and over again and there may be a serious out-
come.

o

RUPTURED INTERVERTE-
BRAL DISKS*

JOHN D. LANE, M. D.

New Orleans

It is now fifteen years since a definite
connection between intervertebral disks and
disabilities of the spine was recognized, and
a definite study begun. But not until the
past five years has its magnitude in patho-
logical conditions of the spine taken the
place it deserves.

Many patients have traveled from one
doctor to another and finally, in search of
relief to the chiropractor and osteopath to
receive the many healing lotions and me-

*Read before the sixty-fifth annual meeting of
the Louisiana State Medical Society, New Orleans,
April 24-26, 1944.

chanical appliances, only to reconcile them-
selves after months or years, that they
were doomed to a life of back ailments,
that came in acute attacks and usually sub-
sided after a time, only to recur after cer-
tain types of activity which they gradually
learned to avoid. As time passed, they
ceased to elicit medical aid, except for pain
pills.

For the early study and initiation of the
development of the present concept of the
role played by intervertebral disks in patho-
logical conditions of the spine, much credit
is due to Schmorl of Dresden, whose origi-
nal work in the anatomy, physiology and
pathology of intervertebral disks has been
a stimulus to further the study and develop-
ment of our present day concept.

The old saying “That a man is as old as
his arteries” also applies to other structures
as well, among these are the intervertebral
disks.

The anatomy of the intervertebral disk is
important to explain the physiology and
pathology of this structure. The disk is
composed of three parts, the cartilaginous
plates which are the boundary between the
vertebral body above and below, and consti-
tutes that part of the disk which is attached
to the bony structure of the two vertebra,
between which the disk is interposed. The
structure of the second component, the an-
nulus fibrosus are the concentric circular
fibrous bands with elastic tissues which re-
tain the invertebral disk laterally. The
annulus fibrosus are most prominent in the
perimeter of the disk. The center or core
consists of the nucleus pulposus and avascu-
lar amorphous substance, which is derived
from the notochord. It has a very high
water content and is somewhat rubbery in
consistency, and readily transmits pressure
in all directions. It is retained by the an-
nulus fibrosus under slight tension, so that
on a cut surface it bulges above the surface
of the other structures.

The contour of the spine is produced to
a large extent by the variations in thickness
of the disks. Also the movements of the
spine are allowed entirely by changes in
thickness and shapes of the disks, rather

Lane — Ruptured Intervertebral Disks

271

than any change in the vertebral bodies.
Another most important function is the ab-
sorption and distribution of the constant
stress and traumas to the vertebra during
activity. But since the disks are avascular
structures, reparative processes following
traumas are very limited, and thus show
more degenerative changes in response to
the same trauma than do the more vascular
vertebral bodies. Therefore it would seem
that disks would often show much more
marked degenerative changes than the cor-
responding vertebra. These conditions have
been repeatedly demonstrated by the ana-
tomical studies of Lusachka, Schmorl and
Smith, who have further demonstrated that
under normal conditions pressures as great
as three hundred pounds are exerted on the
disks in the lumbar spine.

Peatters concludes from the many speci-
mens dissected, that degenerative changes
in the bony structures of the spine, and
that many of the bony changes of the verte-
bral bodies are efforts on the part of the
bodies to stabilize a weakened interverte-
bral space. These degenerative changes in
disks seemed to be directly influenced by
first trauma, and second age.

Degenerative changes in the disk are
demonstrated by dessication with vacuoli-
zation and inelasticity of the nucleus.
Thinning and loss of tensile strength of the
annulus fibrosa, and fragmentation with
thinning of the cartilaginous plates. As the
resiliency of the disk becomes diminished,
its power to transmit forces in all direc-
tions rapidly becomes impaired. Thus each
insult does more injury to the diseased disk
than to a corresponding normal one that
is capable of rapidly changing shape, and
distributing equally the stress and strain.
Thus the vicious cycle continues until there
may be complete disintegration of the
structure. Or due to some sudden strain
with its inability rapidly to change form,
it may rupture the annulus fibrosa with
resulting extrusion of nuclear material
producing a* true herniation. On this basis
one of the two conditions may result which
cause symptoms; a true rupture with her-
niation of the nucleus pulposus or necrosis

of the disk, with narrowing at the disk
space and bulging of the structures into
the surrounding tissues.

PATHOLOGIC PHYSIOLOGY

Since the lower spine receives much more
stress and trauma than the dorsal or cer-
vical spine, it is readily seen that disk
changes will be far more common in this
region than other portions of the spine; by
far the most common site being at the
fourth and fifth lumbar disks. Estimations
of large number of cases being from 95
to 98 per cent.

When rupture or necrosis of a disk does
occur, this may result in narrowing of the
disk space, thus upsetting the normal bal-
ance of the ligamentous and muscular at-
tachments, and at times transferring added
weight bearing on the facets. This added
stress on the lumbar facets may cause re-
laxation of its supporting ligaments, with
narrowing of the intervertebral space.

When a disk is ruptured and the ex-
truded portion is so situated that stress or
pressure is not exerted on the cauda equina,
or nerve roots, the symptoms are usually
local, and those that would be manifested
by any torn or strained ligament are thus
limited to the time for recovery of any torn
ligament. But due to the anatomical ar-
rangement of the lumbar spine and the
cauda equina, this often is not the case.

The most common site of rupture with
herniation of the disk, is posterior into the
spinal canal. This is thought to be due to
the posterior longitudinal ligament being
weaker than the other supporting liga-
ments of the disk, the weakest part of the
posterior ligament being laterally, thus
making this point the most common site of
disk herniation.

This is unfortunate, since it makes the
common site of herniation just beneath the
nerve roots as they leave the cauda equina,
to pass down and out the intervertebral
foramen. There is considerable mobility of
the cauda equina in the lumbar portion of
the spinal canal, except at the exit of the
nerve root, where the nerve with its sleeve
of dura is more or less fixed, it allows lit-

272

Lane — Ruptured Intervertebral Disks

tie movement from pressure or strain, a
very important point in this condition,
since this is a frequent site of herniation.

When there is necrosis of the disk, with-
out actual rupture of the posterior longi-
tudinal ligament, there is a bulging due to
weakening of the annulus fibrosa, which
may cause nerve pressure. The disk space
frequently becomes narrowed, thus placing
added strain on the supporting structures,
especially the facets, and at times narrow-
ing of the intervertebral foramen.

Thus there are two disk conditions which
frequently cause symptoms, the necrotic
disk with breaking down of its normal
structures, and the herniated disk with ex-
trusion of the nucleus pulposus into the
spinal canal.

Thus is seen the excellent opportunity for
the symptoms, both local and referred from
disease or rupture of a disk.

The one time occasionally made diagno-
sis, with its elaborate diagnostic proce-
dures, which were considered necessary to
confirm physical findings, has now become
a common one, made with much less diffi-
culty. Many of the earlier diagnostic pro-
cedures have been discarded as being mis-
leading in too large a percentage of cases.

Rupture and necrosis of the interverte-
bral disk at the fourth and fifth lumbar
spaces, are considered by some leading phy-
sicians by far the most common conditions
causing low back and sciatic symptoms.
Dandy goes so far as to state that rup-
tured disks are as common to the low back
as appendicitis is to the abdomen.

DIAGNOSIS

In making the diagnosis the history is
very important. Since 95 to 98 per cent of
all disks occur at the fourth and fifth lum-
bar spaces, the complaints are most typical
in this location. A history of repeated at-
tacks of low back pain, the first attack be-
ing initiated by some injury, most often
straining, with the back in a stooped posi-
tion for lifting, even coughing or sneezing,
as the initial onset causing acute pain in
the lumbar spine. This local pain is fol-
lowed in from several hours to several days

by pain radiating down the back of one
thigh and leg, over the course of the sciatic
nerve. Coughing, straining or stooping
causes a sudden stabbing pain in the lum-
bar region, and radiating along the course
of the sciatic nerve.

The patient is often forced to bed, or
may limp around with a stiff straight back,
guarding each movement. The acute stage
lasts usually from one to three weeks, pro-
gressing to the chronic stage, the patient
learning gradually what movements to
avoid to prevent pain and discomfort.

Some victims remain in a chronic state,
with low grade back and sciatic symptoms,
being forced to limit their activities to pre-
vent pain or another acute exacerbation of
symptoms. Others have complete recovery
after the initial attack, until the back re-
ceives a second insult. Succeeding attacks
are usually produced by much less violent
trauma than the first, and succeeding at-
tacks tend to be more severe and require
longer to recuperate. These being the typi-
cal symptoms, any combination of these
may be present. The patient at times may
have had an injury so trivial as to omit it
from the history. The pain may be most
acute in the back, thigh or any point along
the course of the sciatic nerve, depending
on the size and location of the ruptured
disk. Back pain may eventually subside,
leaving only the sciatic symptoms or the
reverse may happen.

Paresthesias are common, a complaint of
tingling or numbness, electrical shocks in
the involved dermatone. Paresthesias on
the lateral aspect of the calf, foot, second,
third and fourth toes are most often pres-
ent with lesions at the fifth lumbar inter-
space. When it involves the great toe, me-
dial aspect of the heel and top of the foot,
most often the fourth lumbar space is in-
volved.

The patient often states that the affected
limb has to be favored, and may even com-
plain of weakness of certain groups of
muscles. The physical findings are most
often very characteristic. One of the most
striking features is the peculiar list of the
spine, the pelvis is usually tilted with the

Lane — Ruptured Intervertebral Disks

273

ilium elevated on the affected side, and a
compensatory scoliosis of the lumbar spine
thus widening the disk space at the site of
rupture. Stiffness of the lumbar spine with
loss of normal lumbar curve, associated
with spasm of the sacro-spinalis muscle
group frequently more marked on the af-
fected side is very common. Pressure over
the nerve root and spinous process of the
affected side very often causes pain.

Sometimes these patients are wearing a
built up shoe for shortening of one leg,
which is actually due to tilting of the pel-
vis. Straight leg raising on the affected
side causes pain along the course of the
nerve into the back. Evidence of muscular
atrophy is rare. Anesthesia complete is not
often found due to overlapping of the der-
matones. Zones of diminished sensation or
hyperesthetic zones are often found corre-
sponding to the dermatones of the nerve
root involved. The most common reflex
change is the ankle jerk, which may be
diminished or absent, indicating a rupture
at the fifth intervertebral disk.

Laboratory tests, and spinal puncture
with fluid examination including total pro-
tein, have failed to be an aid in making a
positive diagnosis. Their value has been of
most assistance in ruling out other condi-
tions that may simulate disks in our expe-
rience. The same applies to x-ray exami-
nations, including the injection of contrast
media. It only aids in ruling out other con-
ditions, and in cases where the symptoms
are typical. But always x-ray of the
spine and pelvis should be made before op-
eration to rule out evidence of the other
conditions.

At the present time we are relying prin-
cipally on the history and physical findings,
with negative x-ray findings to make the
diagnosis and locate the disk.

TREATMENT

The treatment of ruptured disks is sur-
gical and requires considerable knowledge
of the structures of the spine and cord.
The major procedure of complete laminec-
tomy to expose the diseased disk has now
been almost entirely replaced by a partial

hemilaminectomy. The severity of symp-
toms and number of acute attacks, plus the
actual disability, are the chief factors to
determine when surgical intervention is
indicated. Some patients have one attack
and, by being kind to their backs, never
have a recurrence. Others after one attack,
go from several months to several years
before a recurrence of symptoms is pro-
duced ; thus one attack does not make oper-
ation imperative.

Much criticism fell upon the surgery of
diseased disks in the early stage, but I think
due to inability to recognize the various
types of diseased ones. Some were ex-
plored and because a large protruding tu-
mor mass was not found beneath the
corresponding nerve root, the wound was
closed and a diagnosis of hypertrophy of
the ligamentum flavum was made. If the
decompression by removing the ligamen-
tum flavum did not help the symptoms, the
diagnosis was considered incorrect.

We have now learned to identify necrotic
disks which cause symptoms, as well as
herniated disks, by testing the mobility of
the adjacent vertebra after exposure, and
the consistency of the disk itself, plus the
narrowing of the disk space. The adjacent
vertebra is hypermotile. Pressure on the
disk with a forcep shows it to be soft and
without normal turgor.

Symptomatic treatments in the form of
physiotherapy, braces, massage and injec-
tions of various kinds are not curative. At
times patients complain that these proce-
dures aggravate the condition.

When operation is deemed necessary, the
surgical procedure should be directed to-
ward relieving the symptoms and restoring
the part to its normal function. If the ma-
jor symptoms are sciatica, the primary ob-
ject is to relieve the irritating source to the
nerve root. If the chief symptoms are lo-
cated in the lumbar region and thigh, the
chief concern should be directed towards
stabilizing the hypermotile and weakened
intervertebral disk.

It has been demonstrated that narrowing
of the disk causes a disturbance in the nor-

274

Lane — Ruptured Intervertebral Disks

mal weight bearing alignment in both the
vertebral body and its facets.

Since the weight bearing surfaces of the
facets are directed in a more vertical direc-
tion in the lumbar spine rather than the
horizontal, the added stress is thrown on
the ligamentous structures which bind the
facets together.

With this added stress there is ultimate
relaxation and settling of the facets. This
often causes narrowing of the correspond-
ing intervertebral foramen. This may im-
pinge on the nerve root as well as cause
local back pain. The narrowing can often
be demonstrated by hyperextending the
spine, producing local back pain and some-
times sciatic radiation.

OPERATIVE PROCEDURES

In carrying out the above principles our
operative procedure consists of a hemilami-
nectomy of the fourth or fifth lumber ver-
tebra, or both if indicated. The lamina
removed depends on the physical findings.
The ligamentum flavum is completely re-
moved with the lamina. Enough bone is
always removed to allow adequate examina-
tion of the nerve root, its corresponding
disk and intervertebral foramen. The nerve
is examined for edema or other abnormali-
ties, then retracted medially. If there is
found a definite herniation of the disk so
situated that it produces pressure on the
corresponding nerve root or the cord, the
posterior longitudinal ligament is incised if
still intact. The herniated portion of the
disk is then thoroughly removed, and the
remaining portion of the disk is then ex-
amined to determine if this portion is intact
and of normal consistency. If the remain-
ing portion appears stable, it is left un-
disturbed. If the examination shows the
unextruded portion of the disk to be in the
process of degenerating, the opening in the
longitudinal ligament is enlarged to permit
the entrance of a moderate size curette into
the disk space. All of the necrotic and de-
generating nucleus is removed, including
the cartilaginous end plates. The end
plates are removed to promote fusion be-
tween the vertebral bodies and thus to sta-
bilize the weakened disk.

After removal of necrotic material from
the disk space, often there remains a large
size cavity. If this is not corrected, there
will be a narrowing of the space and a
tendency for the adjacent vertebrae to come
together before bony union occurs. If this
is allowed to take place, there will be cre-
ated an imbalance in the weight-bearing
surface of the vertebral bodies and corre-
sponding facets, which can easily be re-
sponsible for later symptoms.

To prevent this narrowing of the disk
space and maintain normal relationship be-
tween the adjacent vertebra, a bone peg is
prepared and wedged between the vertebral
bodies in the space previously occupied by
the necrotic portion of the disk. Besides
maintaining the proper disk space, the bone
wedge also tends to aid the process of bony
fusion between the bodies of the vertebra.
The bone wedge is prepared from a portion
of the spinous process of the vertebra above
the diseased disk. The spinous processes in
the lumbar region are thick and wide and
always furnish ample bone. By removing
one-half, never over three-fourths, a bone
wedge which fits firmly between the verte-
bral bodies can be made.

%

After insertion into the disk cavity, the
porterior aspect of the wedge is driven lat-
erally. This is done to remove the peg from
beneath the opening in the longitudinal lig-
ament, thus preventing it from being ex-
turned back into the vertebral canal in case
it should loosen within the disk cavity.

Following the graft procedure, various
sized gall bladder duct probes are passed
into the intervertebral foramen of the cor-
responding nerve root to determine if there
is adequate space to prevent pressure on the
nerve.

The wound is then closed in layers and
dressing applied. The patient is allowed to
turn and adjust the position to the most
comfort in bed. He is allowed to sit up
on the ninth or tenth day and to become
ambulant by the twelfth day. Light duty is
resumed at the end of four weeks, arduous
use of the back not before eight weeks.

The bone peg procedure seems to be
somewhat more physiological than the

Lane — Ruptured Intervertebral Disks

275

spina! graft of the Albee type frequently
used to stabilize hypermotile vertebral
bodies.

This procedure tends to stabilize the ap-
pendages of the vertebra, rather than the
weight-bearing surface itself, whereas the
bone peg procedure maintains the disk
space and tends to stabilize the vertebral
body through its normal weight-bearing
surface.

The added time consumed in preparing
the bone peg from the spinous process and
wedging it between the vertebral bodies
consumes approximately fifteen minutes,
whereas the more extensive spinal graft
consumes much more time, which is to be
considered when added to the length of the
time for the operation on the disk.

SUMMARY

At the Marine Hospital at Newr Orleans
136 operations for diseases of the interver-
tebral disk have been performed since
1939. The follow-up of this series is not en-
tirely complete since a majority of these
cases are merchant seamen, and after they
return to sea many cannot be contacted.

The average duration of symptoms previ-
ous to operation was 18 months. At the
time of return to duty 102 patients stated
that they had complete relief of symptoms ;
28 had slight residual symptoms but were
able to return to their usual occupation ; six
have been considered as complete failures.
Fifty-three men have been followed over a
period of 22 months or longer, 48 of whom
have been free from symptoms; two have
returned for observation, one of whom was
reoperated for a second disk, the other was
later proved to have a sarcoma of the ilium.
The remaining three patients have been
confined to light duty since laborious duty
caused some recurrence of symptoms.

There was one death in the 136 cases.
The postmortem findings were reported as
pneumonia and brain damage secondary to
anoxemia probably from the anesthetic.
No evidence of meningitis was found.

In the entire series there have been three
recurrences confirmed by operation.

DISCUSSION

Dr. Dean H. Echols (New Orleans) : I did not
have an opportunity to read this paper before-
hand and consequently have not prepared a for-
mal discussion. I do not want to make any criti-
cisms of what has been said, since I agree with
everything, but will confine my remarks to several
points which have not been discussed.

Dr. Lane is one of the few general surgeons in
the United States who has had extensive experi-
ence with disk surgery; I doubt if any general
surgeon anywhere has had a larger series of cases.
Most disk surgery is done by neurosurgeons or
orthopedic surgeons. However, Dr. Lane practices
under unusual conditions. Orthopedic advisors are
readily available to him and he is able to combine
orthopedic, neurosurgery and general surgery very
well. In civilian practice it seems undesirable for
the general surgeons to do disk surgery, and only
a few, if any, have wanted to. Most of the ortho-
pedic surgeons in this country have left ruptured
disks to the neurosurgeons. However, ruptured
disk is not entirely a neurosurgical problem. The
vertebral column is a part of the body which be-
longs also to the orthopedists; this seems like a
paradox yet the solution works out very nicely. It
is my opinion that the neurosurgeon should not
do a disk operation until the orthopedic consultant
has had a chance to examine the patient and treat
him by conservative orthopedic measures. If the
orthopedist finds a ruptured disk and decides that
the patient can not get well the neurosurgeon
should then take the case. However, if the ortho-
pedist thinks he can provide relief, he should have
the opportunity to treat the patient.

As for my own record, I can say I have never
operated on a patient with ruptured disk who has
not first been examined (and usually treated) by
an orthopedic surgeon. At first I was skeptical
about what the orthopedic surgeon could do with
a ruptured disk and told patients not to be opti-
mistic. However, in many cases traction and a
plaster cast have relieved the patient and he has
remained well.

Perhaps I should supplement Dr. Lane’s re-
marks about technic by pointing out that there
are several ways of handling disks surgically.
Simple removal of part of the disk is the opera-
tion practiced by most neurosurgeons in this
country. Some surgeons believe in curetting the
cartilaginous plates of the disk so that fusion can
possibly take place between the vertebral bodies
and prevent the possibility of residual back pain.
The bone peg technic, as used by Dr. Lane, has
been found to be very good in his hands. For the
past year and a half in certain cases I have not
only curetted the disk but I have broken through
into the bodies of both vertebras so that there is
more chance for fusion.

Dr. Lane closed the discussion with slides.

276

Romagosa and Rackley — Orbital Cellulitis

ORBITAL CELLULITIS WITH SEVERE
CEREBRAL SYMPTOMS

(Possible Cavernous Sinus Thrombosis)

SUCCESSFUL TREATMENT WITH COM-
BINED SULFONAMIDE-PENICILLIN
THERAPY

JEROME ROMAGOSA, M. D.

AND

G. D. RACKLEY, M. D.

Opelousas, La.

This is the report of a case of severe or-
bital cellulitis possibly complicated by cav-
ernous sinus thrombosis, in which, although
the prognosis at the outset seemed very
grave, complete recovery followed therapy
with sulfonamide drugs, penicillin, and
later, drainage of a supra-orbital abscess.

CASE REPORT

J. G., white female, aged 13, was first seen by
one of us (J. R.) on January 19, 1944, with the
complaint of frontal headaches of three days’ dura-
tion. At this time there were no signs of local
disease in the painful region, and the patient was
afebrile. Mild tonsillitis and pharyngitis were
present. Two days later there occurred slight
fever, and on January 22, six days after the onset
of the headache, swelling of the forehead and left
eyelid was noted. On this day there occurred sev-
eral chills followed by high fever. Early in the
morning of January 23 the mother noted that the
child was delirious. Examination later the same
day revealed the patient to be comatose, with
temperature of 103° F., and with extremely rapid
pulse, the rate as nearly as could be counted being
about 200 per minute. There was marked pallor,
with cyanosis of the lips and fingernails. The left
eyelid and supra-orbital region were markedly
swollen and the eyelids were reddish purple in
color. There was conjugate deviation of the eyes
to the left, with occasional coarse nystagmus-like
movements. The pupils were round and equal and
reacted to light, and the optic fundi appeared nor-
mal. The ears were normal otoscopically, and there
were no signs of disease in the nose. The heart,
lungs, and abdomen were normal to physical ex-
amination. The neck was not rigid and there were
no other signs of meningitis. It was believed at
that time that the patient was in a moribund state.

The patient was immediately transferred to the
St. Landry Hospital, and soon after arrival began
to have convulsions. At first these involved only
the face and hands but later there occurred four
or five generalized convulsions, each lasting from

five to ten minutes. The convulsions stopped after
two subcutaneous injections of sodium phenobar-
bital (.065 gm. each). Shortly after admission
she was given 3 gm. of sodium sulfathiazole intra-
venously. Coma continued for about eight hours
after the injection, but thereafter the patient be-
gan to clear mentally and was able to take nour-
ishment. Sulfamerazine in usual dosage was then
given by mouth. On the next day the patient was
clear mentally, pulse rate had markedly decreased,
and the maximum temperature was 104°. On this
day therapy with penicillin was begun, 10,000 units
of the drug being given intramuscularly every four
hours. Sulfamerazine was continued by mouth.
Steady improvement in the general condition of
the patient continued thereafter, although the
swelling increased and involved the left temple
region as well as the eyelids and forehead.

On January 27 fluctuation appeared in the cen-
ter of the edematous region of the forehead, and
the edema of the eyelids and temple region had
somewhat diminished. An x-ray of the skull on
this day showed no evidence of bone disease. Max-
imum temperature on this day was 101°.

On January 28 the fluctuant region was incised
under nitrous oxide anesthesia with the evacuation
of about 30 c. c. of pale green pus. Thereafter
the temperature did not exceed 100° and remained
normal after February 2.

The use of penicillin and sulfamerazine was
discontinued on January 30, total dosage of sulfa-
merazine having been 20 gm., and of penicillin
220,000 units.

The edema rapidly decreased after incision of
the abscess, which drained for only four days.
Two blood cultures were taken during the course
of the illness, both of which were negative.

On February 2 the patient was discharged from
the hospital, and by February 15 was apparently
completely well and was allowed to return to school.

COMMENT

It is certain that this patient had severe
orbital cellulitis with beginning extension
backward into the cranial cavity and with
possible thrombosis of the cavernous sinus.
It is almost certain that without chemo-
therapy death would have occurred before
localization of the infection and abscess
formation had taken place. It is difficult
to evaluate the relative roles played by the
sulfonamide drugs and penicillin in this
case since they were administered conco-
mitantly. It should be noted, however, that
marked improvement occurred after the
intravenous administration of sulfathiazole
before penicillin could be obtained.

Ochsner and Kefl — Cancer Report

277

YEARLY REPORT OF THE CANCER
CLINIC AT CHARITY
HOSPITAL

ALTON OCHSNER, M. D.f

AND

MAXWELL F. KEPL, M. D.f
New Orleans

The Cancer Clinic was organized at Char-
ity Hospital in February, 1943, its main
purpose being to serve in the capacity of an
out-patient clinic where patients could be
referred from either the admitting room
directly, from other out-patient clinics, or
from the medical, radiological and surgical
wards for diagnosis and treatment.

Its primary purpose was to obtain the
opinions of specialists in surgery, pathology
and radiology so that the patient could ob-
tain the benefits from the consensus of
opinions.

After a positive diagnosis was established
and after treatment was decided upon, the
patient was referred to that department
which treated such conditions.

Through the excellent aid of the Social
Service Department of Charity Hospital
and through the untiring efforts of Mrs.
Henry Miles, the personal representative of
the Women’s Field Army for Cancer Con-
trol, we were able to get complete “follow-
up” records on 112 of the 138 cases ad-
mitted to the clinic for the year.

There were 38 white males and 48 fe-
males. There were 26 colored females and
seven colored males. The white males made
87 visits and the white females 139. The
colored females made 107 visits and the col-
ored males 19. For the 112 patients whose
records were followed there were 352 visits.
Each patient made an average of 3.14 visits
to the clinic.

Biopsies were made in 20 white males
and 20 white females, 11 colored females
and five colored males.

Of the white males, three had no tumors
and in three the tumors were not malig-
nant. Of the white females, two had no

fFrom the Department of Surgery, School of
Medicine, Tulane University, New Orleans.

tumors and in five the tumors were not
malignant. Of the colored females, four had
no tumors and in four the tumors were not
malignant. Of the colored males, one had
no tumor and in one the tumor was not
malignant.

Of the 38 white males, 23 had proved
carcinoma and two had proved sarcoma. Of
the 48 white females, 28 had proved carci-
noma and one sarcoma. Of the 26 colored
females, 14 had proved carcinoma and one
sarcoma. Of the seven colored males, three
cases had carcinoma and one sarcoma.

Of the white males, nine patients were
treated with radium, 17 with x-ray and
eight were treated surgically. Of the white
females, two were treated with radium, 18
with x-ray and 18 with surgery. Of the
colored females, one was treated with ra-
dium, 11 with x-ray and 18 with surgery.
Of the colored males, one was treated with
radium, two were treated with x-ray, four
with surgery and one had no treatment.

Of the white males, one case was consid-
ered inoperable. Of the females, both white
and colored, and the colored males, none
was considered inoperable.

Of the white males, the most common
type of carcinoma was that of the lip, seven
cases being found. In the females, both
white and colored, the most common type
of lesion was carcinoma of the breast, eight
cases occurring in each race. In the colored
males the number of cases was too small to
draw any conclusions.

The most common lesion in white males
was inflammatory granulation tissue. In
white females the most common lesion was
cystic mastitis. In colored females the most
common benign tumor was lipoma and ke-
loids, while in colored males the number of
cases was insufficient to draw any conclu-
sion.

In white males the age ranged from 5 to
81 with an age average of 56.5 years. In
white females the age ranged from 4 to 86
with an age average of 53.9 years. In col-
ored females the age ranged from 5 to 70
years with an age average of 42.3, while in
colored males the age ranged from 13 to 59
years with an age average of 44.

278

Ochsner and Kepl — Cancer Report

Of the white males there were two re-
currences, one following surgery and the
other following surgery and x-ray. In the
white females there were two recurrences,
one following surgery and the other follow-
ing surgery and x-ray therapy. In colored
females there were two recurrences, one
having been treated with surgery alone and
the other having received both surgery and
x-ray treatment. There were no recur-
rences in the colored males.

Of the rare malignant tumors seen in the
white males, a lymphosarcoma of the right
tonsillar region was observed, while of the
benign tumors a hemangioma of the skull
was observed. A very interesting case ob-
served which was not a tumor was that of
a patient who had the x-ray appearance of
carcinoma of the lung for which a pneumo-
nectomy was performed and which was
found on histological examination to be
lipoid pneumonia.

The most interesting benign tumor was
an osteoma of the jaw.

The most interesting malignant tumor in
white females was a carcinoma of the kid-
ney which showed tumor cells involving the
renal vein at operation, which later metas-
tasized through the body. This patient is
still alive two years after operation. An-
other rare type of malignant tumor seen
in a white female was a primary carcinoma
of Bartholin’s gland with metastasis to
the inguinal region.

In the colored females, the most interest-

ing benign tumor was a keloid of the breast.
The most interesting lesion that was not a
tumor was gumma of the sternum.

The most interesting case in the colored
males was that of a carcinoma of the stom-
ach treated by surgery with a two year
“follow-up” with no sign of recurrence.
The most interesting benign tumor in col-
ored males was a cavernous lymphangioma
of the tongue.

It is realized that this report is incom-
plete ana has little significance to the stat-
istician who is interested in five and ten-
year cures. It is hoped, however, that the
continuance of such a yearly report will
give valuable information over an extended
period of time. Deep appreciation is given
Dr. Bjarne Pearson and Dr. Manuel Garcia
for their efforts and excellent advice and
without whose help this study would have
been impossible. The Women’s Field Army
for Cancer Control and the Social Service
Department of Charity Hospital aided
greatly in the successful management of the
social side of the clinic. It is hoped that
the continuance of such a clinic with the
availability of expert medical knowledge
combined with adequate “follow-up” will
permit the earlier diagnosis of cancer and
diminish the appalling death rate from this
disease. We believe that a close cooperation
between all of the medical specialists is nec-
essary in order to attain such a goal, and
that cancer in its early stages can be cured.

Editorials

279

NEW ORLEANS

Med ical and Surgical Journal

Established 18

Published by the Louisiana State Medical Society
under the jurisdiction of the following named
Journal Committee:

Val H. Fuchs, M. D., Ex officio
For two years: G. C. Anderson, M. D., Chairman
Leon J. Menville, M. D.

For one year: J. K. Howies, M. D., Vice-Chairman
For three years: C. Grenes Cole, M. D., Secretary
E. L. Leckert, M. D.

EDITORIAL STAFF

John H. Musser, M. D Editor-in-Chief

Willard R. Wirth, M. D Editor

Daniel J. Murphy, M. D Associate Editor

COLLABORATORS— COUNCILORS

Edwin L. Zander, M. D.

J. T. O’Ferrall, M. D.

Guy R. Jones, M. D.

T. B. Tooke, Sr., M. D.

George Wright, M. D.

W. E. Barker, Jr., M. D.

C. A. Martin, M. D.

W. F. Couvillion, M. D.

Paul T. Talbot, M. D... General Manager

1430 Tulane Avenue

SUBSCRIPTION TERMS: $3.00 per year in ad-
vance, postage paid, for the United States; $3.50
per year for all foreign countries belonging to the
Postal Union. ■

News material for publication should be received
not later than the eighteenth of the month preced-
ing publication. Orders for reprints must be sent
in duplicate when returning galley proof.

Manuscripts should be addressed to the Editor,
H30 Tulane Avenue, New Orleans, La.

The Journal does not hold itself responsible for
statements made by any contributor.

THE EMIC

It has been said that the EMIC is the
guinea pig for future medical service acts.
If such is the case the physicians who have
had dealings with EMIC can appreciate
and will realize what they will be up
against were there to be passed by Con-
gress a comprehensive Federal medical act
such as the Murray-Wagner-Dingell Bill. As
far as can be determined the whole EMIC
has been a tremendous failure in its admin-
istration. Almost daily difficulties have

arisen with the Washington bureaucrats.
If satisfaction is given to but few physic-
ians in the spending for forty-two million
dollars it is almost impossible to imagine
how funds amounting to three to twelve
billion dollars would be properly adminis-
tered. The stream of directives and orders
which flow from Washington headquarters
of the Children’s Bureau are conflicting and
many of them made without knowledge of
state or local conditions. One should not
wonder at this confusion because after all
most of the officials who issue directives
are persons who have fallen into a bureau-
cratic job when they have failed in their
civil life activities.

We, as physicians, are bothered to a
limited extent in filling out forms in the
care of maternity patients who come un-
der EMIC. Imagine what difficulties, how
much paper work and how much filling in
of forms would be necessary did a doctor
have to send in to Washington forms, cer-
tificates and what not concerning the pa-
tients who will make up 90 per cent of his
practice under regimented medicine. At the
present time big business is submerged in
filling out innumerable questionnaires and
sending in bits of information to Washing-
ton ; most of these data pile up in an office
and are never used. It has been said the
Johns-Manville Company is obliged to send
to Washington a form every two minutes of
the day and at a cost of somewhat under
a million dollars. Again we reiterate that
these innumerable forms are often buried in
the archives, filing cabinets or desks and
never used.

The bureaucrat feels that he is in a po-
sition of a dictator. What he says has to
go and that too often irrespective of the law
or the way the directive was issued. In the
instance of the EMIC, the distinct wording
of the law is plain, that the planning should
be done by the states and then approved by
the Children’s Bureau, but on the contrary
the Children’s Bureau has issued orders
how things should be done, what they ex-
pect to be done, the way they want it done
and the states have been completely disre-
garded or over-ridden.

280

Editorials

MEDICAL CERTIFICATION

Elsewhere in the Louisiana section of the
Journal is a communication from Dr. Eddy,
medical director of the Louisiana Ordnance
Plant, which we would like to call to the
thoughtful attention of the medical profes-
sion of Louisiana. We have heard many se-
vere criticisms, not so much in our own lo-
cality but elsewhere of physicians who have
improperly certified to a man’s needs or
his hypothetical illness. However, there has
been some criticism of our Louisiana doc-
tors relative to issuing certificates but we
have not heard of any very flagrant breach
of medical ethics in regard to certificates
issued by Louisiana doctors, examples of
which disregard of the proprieties are be-
ing talked about throughout the country. It
does seem, however, that there is a tenden-
cy for the family physician to issue certifi-
cates for the use of unneeded cream, or for
gasoline, or for some other purpose simply
as a favor to friends and to patients. This,
of course, is for the most part of minor
moment but nevertheless it has become al-
most a custom for the doctor to give certifi-
cates on very questionable grounds merely
to be obliging or to put some one under ob-
ligations to him.

Because of the great need of workers in
war jobs and because many of these work-
ers feel that they want to get back to their
civil occupation, and because this is diffi-
cult with the present War Manpower Com-
mission regulations, of extreme importance
to our war efforts is the fact that medical
certificates are being used widely in order
to obtain release from war work. This is
helping to create a gradual diminution in
the number of war workers now when the
problem of getting sufficient personnel to
make shells, to load them, to construct
heavy tires, to weave canvas, and to meet
the requirements of supp’y of the armed
services is becoming more and more acute.
We must do our part as physicians to keep
the war workers at work. The issuing of a
certificate of illness or of ill health is a
definite responsibility. It should not be done
lightly. If we do not accept this responsi-
bility it will be difficult for us to maintain

our place of honor and dignity in our com-
munity and in our country.

o

PENICILLIN IN EYE INFECTONS

It has been established quite definitely
that penicillin is of little value in the treat-
ment of infections caused by filtrable vir-
uses or by Gram-negative bacilli ; conse-
quently the drug has not been helpful in
the treatment of brucellosis or of typhoid,
of influenza and many other conditions
which might come to mind, but reports are
coming in now of its great value in the
treatment of syphilis.

There is difficulty in the administration
of penicillin because of its rapid elimina-
tion in the urine and because it cannot be
given by mouth. Necessarily its use has
been limited then to severe infections. How-
ever, now that penicillin has become avail-
able for general use it has been found that
it is of real worth when applied locally in
the treatment of many skin conditions. Ac-
tually it is an ideal antiseptic. It is non-toxic,
has tremendous antiseptic power and it acts
in any type of medium. The most recent use
of penicillin has been in the treatment of
superficial infections of the eye and the eye-
lids. Experimentally, it has been shown that
it will penetrate into the anterior chamber
of the eye of the rabbit. This can be done
merely by instillation of penicillin solution
or ointment. Crawford and King* have
treated patients who had conjunctivitis
of considerable severity, people who had
corneal infiltrations with corneal ulcers,
and some with severe blepharitis. The study
of these authors shows that penicillin-treat-
ed patients improved more rapidly than did
the controls. They found it to be a most ef-
fective drug merely when applied locally to
the mucous membrane of the eye. The con-
junctivitis, the corneal ulceration and the
blepharitis disappeared in a comparative-
ly few days; the milder cases on an aver-
age of five days and the more severe from
seven to nine days. The form of applica-
tion was either a solution of penicillin, 250-

♦Crawford. T„ and King, E. E. : Value of penicillin in
treatment of superficial infections of eye and lid margins,
Brit. J. Ophthal., 28:375, 1944.

Organization Section

281

500 units per cubic centimeter in sterile wa-
ter or as in the instance of corneal ulcera-
tion, an ointment was used every four
hours, the ointment containing 200 units of
penicillin per gram. The patients were fol-
lowed by bacteriologic studies. It was found
that within a few days the conjunctival
swabs became sterile. The authors advise

the continuation of treatment for some days
after sterility has been obtained or for at
least seven days after full clinical recovery
in the more severe cases.

The results with penicillin in the treat-
ment of eye infections would indicate that
a new field has been opened for the use
of the “wonder drug.”

ORGANIZATION SECTION

The Executive Committee dedicates this page to the members of the Louisiana
State Medical Society, feeling that a proper discussion of salient issues will contri-
bute to the understanding and fortification of our Society.

An informed profession should be a wise one.

ANNUAL CONFERENCE OF SECRE-
TARIES AND EDITORS, CHICAGO

The Annual Conference of State Secre-
taries and Editors was held in Chicago at
the American Medical Association head-
quarters on November 17 and 18. Attend-
ing this meeting also were several presi-
dents of state medical societies. The pres-
ident of the Louisiana State Medical So-
ciety, along with the editor of the Journal
and the secretary-treasurer represented the
organization ; it is felt that you would
appreciate knowing some of the important
problems that were discussed at the meet-
ing. Here was a gathering representing the
forty-eight states which gave a fairly ac-
curate representation of a cross section
view of the country. About one hundred
and fifty representatives were in attend-
ance. The proceedings were very intense on
Friday and up to twelve-thirty on Satur-
day. The preliminary functions were as
usual with the executive officers of the
American Medical Association making in-
troductory remarks after which the group
settled down to serious and sincere listening
and discussing of pertinent medical prob-
lems of the day. May I direct your atten-
tion to a few of these as follows:

The EMIC program as presently consti-
tuted received severe condemnation, espe-
cially brought out by the essayists from the
State of Iowa. This was fortified by a hu-
morous discourse of the various conflictions
of the plan by the state health officer of

Indiana. The results of the thoughts on
this subject were concentrated in the ne-
cessity for the passage of the Miller bill
which would remove from the Children’s
Bureau the supervision and control of the
activities of this program. It was brought
out that Congress never intended for such a
usurpation of authority by the Children’s
Bureau in creating disturbing rules and
regulations contrary to the principles of or-
dinary practice of medicine ; thus delay and
criticism were produced to the disadvantage
of the physicians and the patients. It is
gratifying to know that the position taken
by our state last year in regard to the EMIC
plan, and also by some of the parish medical
societies in objecting to these directives,
was more or less confirmed by other states.

Another topic of serious and profound
discussion which lasted until the late hours
of the evening was the question of prepay-
ment medical insurance. The good points
and the bad points of various systems
throughout the United States were liberally
discussed and very heatedly argued by op-
ponents of one or another plan. It was
basically the opinion of all, however, that
some form of prepayment medical insur-
ance should be adopted promptly by the
various states on a state level if we expect
to defeat or prevent the passage of the
Wagner-Murray-Dingell bill. There are at
present some thirty-six states with a work-
ing prepayment plan with vast experience
which would be most useful in the culmina-

282

Organization Section

tion of any instructive plan for any state.
Their successes and failures form a ready
nucleus and if observed properly would
help mold successfully any medical insur-
ance plan. This observation was very im-
pressive and certainly instilled in one the
necessity of studying most seriously such a
problem for our state.

Another topic for discussion which should
be of interest was one of physical fitness.
Quite a reference was made to this subject
in the November issue of the Journal. There
was one special feature in regard to the
physical fitness, however, which developed
at this conference which should be of great
concern. The medical profession has a seri-
ous responsibility in this movement. Or-
ganizations are being formed in the state
and every doctor in his locality should with-
out hesitancy take an active and personal
interest in helping to mold and direct the
physical fitness program in his town or
parish. This is important. Unless the medi-
cal profession assumes this responsibility
you can expect lay groups and possibly some
other extraneous medical groups and phy-
sical culturists to be only too glad to worm
their way into this program. Here is truly
a need for the awakening of the medical
profession to their responsibility and not
let it be supplanted by any other agency. If
we are going to have a physical fitness pro-
gram in our state we must have it directed
and guided by the medical profession of this
state. So do not fail when this begins to
develop in your locality to take the interest
and enthusiasm that is required.

NUTRITION CONFERENCE

There was held in Baton Rouge on No-
vember 1 and 2 a Conference on Nutrition
in which the Louisiana State Medical So-
ciety was represented by one of its officers.
This is a problem which should be of seri-
ous concern to the doctors of this state, as
it has been brought out that so many of
our diseases are due to faulty nutrition and

can be so easily corrected. The question of
nutrition and its proper usage is one of the
essential features of a good physical fitness
program, being one of the several funda-
mental rudimental factors in the develop-
ment of healthy children before and after
school life. Not only is it necessary to edu-
cate our school teachers and authorities on
the common evidences of nutrition defi-
ciencies, but a much more comprehensive
and broader plan which would take in par-
ents of children before reaching school age.
We know that our physicians will take the
proper attitude in helping direct and sup-
port nutrition programs which might be
evolved in their respective towns or par-
ishes, another great responsibility of our
medical profession.

ANNUAL MEETING 1945

The Executive Committee of the Louis-
iana State Medical Society met on Novem-
ber 11 and transacted the usual routine
business. It was decided to have only a one
day meeting in New’ Orleans on Friday,
April 13 for the meeting of the House of
Delegates. This meeting would be on lines
similar to that held in 1943 in Baton Rouge.
The Executive Committee in making this
decision found it absolutely necessary ow-
ing to the war conditions, affecting hotel
reservations, accommodations for exhibi-
tors, meeting halls, and railroad transporta-
tion, all of w’hich if arranged for eventual-
ly would be subject to change over night by
military necessity. The New Orleans Grad-
uate Medical Assembly is going to hold its
annual meeting in New Orleans on April
9-12, so our meeting W’ill follow on Friday
after the completion of their meeting on
Thursday. This w7as thought to be wise as
it would give our membership an oppor-
tunity to attend the valuable lectures of the
Graduate Medical Assembly previous to the
meeting of our House of Delegates on the
13th. It is, therefore, hoped that this deci-
sion of the Executive Committee for the
benefit of our organization will warrant
your approval and support.

Orleans Parish Medical Society 283

TRANSACTIONS OF ORLEANS PARISH MEDICAL SOCIETY

CALENDAR OF MEETINGS

December

4.

Board of Directors, Orleans Parish
Medical Society, 8 p. m.

December

5.

Eye, Ear, Nose and Throat Staff,
8 p. m.

December

6.

Clinico-pathologic Conference, Ma-
rine Hospital, 7 :30 p. m.
Mercy Hospital Staff, 8 p. m.

December

7.

Clinico - pathologic Conference,
Touro Infirmary, 11:15 a. m.
to 12:15 p. m.

Executive Committee, Baptist
Hospital, 8 p. m.

December

11.

Scientific meeting, Orleans Parish
Medical Society, 7:15 p. m.

December

13.

Touro Infirmary Staff, 8 p. m.
Woman’s Auxiliary, Orleans Par-
ish Medical Society, Orleans
Club, 2 p. m.

December

15.

I. C. R. R. Hospital Staff, 12:30
p. m.

December

18.

Hotel Dieu Staff, 8 p. m.

December

19.

Charity Hospital Medical Staff,
8 p. m.

December

20.

Charity Hospital Surgical Staff,
8 p. m.

Clinico - pathologic Conference,
Marine Hospital, 7 :30 p. m.

December

21.

Clinico - pathologic Conference,
Touro Infirmary, 11:15 a. m.
to 12:15 p. m.

December

22.

Board of Directors, Orleans Par-

ish Medical Society, 8 p. m.
December 26. Baptist Hospital Staff, 8 p. m.
December 27. French Hospital Staff, 8 p. m.
December 28. Clinico - pathologic Conference
Touro Infirmary, 11:15 a. m.
to 12:15 p. m.

DePaul Sanitarium Staff, 8 p. m.

NEWS ITEMS

October 22-29 was observed as National Hear-
ing' Week. The Louisiana League for the Hard
of Hearing, of -which Drs. F. R. Gomila, E. L.
Zander, J. F. Crebbin and William Wagner are
among the officers and directors, planned an in-
tensive program, which included lip reading
classes, the demonstration of hearing devices, and
the demonstration of the multiple hearing aid at
a book review. The purpose of the observance
of this week each year is two-fold, to acquaint the
hard of hearing with what can be done to alleviate
their condition, and to bring before the public the
problems and needs of those who are thus handi-
capped.

Dr. John M. Whitney attended the war confer-
ence of the American Public Health Association
in New York City in October. He also attended
a showing of new food sanitation equipment dis-
played in Chicago by the National Restaurant As-
sociation.

At a symposium on the heart and circulation
conducted under the auspices of the Louisiana State
University School of Medicine, October 25-27, lo-
cal speakers included Drs. George Burch, William
A. Sodeman, Travis Winsor, J. H. Musser, John
S. LaDue, Edgar Hull and Manuel Gardberg.

Dr. Waldemar Metz and Dr. Neal Owens con-
ducted a clinic and demonstrated patients at the
conference in New Orleans in October of the
American Society of Plastic and Reconstructive
Surgery.

At a recent postgraduate review in traumatic
and emergency surgery at Tulane University
School of Medicine local speakers included Drs.
J. L. Wilson, Sam Nadler, J. L. Dixon, Neal Owens,
Dean Echols, Alton Ochsner, Guy Caldwell, Rawley
H. Penick and George Burch.

Dr. Theodore L. L. Soniat, who is now stationed
at the Army Air Forces Regional Hospital at Drew
Field, Florida, has been promoted from captain to
major.

Dr. John E, Schenken addressed the Second Dis-
trict Medical Society of Florida, October 19, on
the relationship of hormones to cancer and on the
pathology of amebiasis.

Dr. Maud Loeber spoke on “Security for Post-
war Children” at the annual convention of the
National Council of Catholic Women in Toledo,
October 21-25. Dr. Loeber is adviser on health
of the Council committee on family and parent ed-
ucation, and is a member of the Board of Di-
rectors.

Dr. W. A. Sodeman, chairman of the committee
on nutrition of the local chapter of the American
Red Cross, has announced that the standard nutri-
tion course has again been accepted by the Orleans
Parish School Board as part of the high school
curricula in both white and negro schools.

Dr. C. S. Wood was elected president and Dr.
W. C. Beil secretary of the Eye, Ear, Nose and
Throat Hospital at the annual meeting of the
staff. The program for the meeting included
plans for the proposed enlargement of the hospital
and for extensive research wTork in disease of the
eye, ear, nose and throat.

Dr. Julius L. Wilson, president of the American
Trudeau Society, spoke on the part of the general

284

, Louisiana State Medical Society News

hospital in tuberculosis control at the convention
of the American Hospital Association in Cleve-
land, October 2-6.

Dr. John M. Whitney was recently elected first
vice-president of the Kiwanis Club.

Dr. Daniel J. Murphy was recently elected a di-
rector of the Mid-City Kiwanis Club.

The following members of the Orleans Parish
Medical Society were on the program of the South-
ern Medical Association at the thirty-eighth an-
nual meeting in St. Louis, November 13-16:

Dr. John Adriani opened the discussion of Major
Ralph S. Sappenfield’s paper on, “Use of Intra-
venous Morphine for Preanesthetic Sedation”; Dr.
Rupert E. Arnell spoke on “Intercurrent Eclamp-
sia”, he also opened the discussion of Drs. Alfred
Habeeb and Hiram R. Elliott’s paper on, “Spinal
Anesthesia for Cesarean Section”; Dr. Donovan
C. Browne opened the discussion of Dr. John Til-
den Howard’s paper on, “Experiences with the
Gastroscope over a Period of Six Years”; Dr. Guy
A. Caldwell and Dr. Donald T. Imrie presented a
paper on, “Treatment of Infantile Paralysis”, they
also presented a motion picture on, “Treatment of
Infantile Paralysis: Acute and Subacute Stages”;
Drs. Vincent J. Derbes, Hugo T. Engelhardt and

T. A. Watters presented a paper on, “The Man-
agement of Migraines”; Dr. Ernest Carroll Faust
spoke on, “Some Clinical and Public Health Haz-
ards in the Southern United States”; Dr. H. W.
Kostmayer spoke on, “Medical Education Above
the Undergraduate Level”; Dr. Luc-ien A. LeDoux,
“Response to the Addresses of Welcome from the
Southern Medical Association”; Dr. Rawley M.
Penick, Jr., spoke on, “Preauricular Sinuses: Diag-
nosis and Treatment”; Dr. John T. Sanders spoke
on, “Some Factors Influencing Mortality and Mor-
bidity in Gynecological Surgery”; Dr. Harry A.
Senekjie presented a paper on, “An Inquiry into
the Growth Factor or Factors of Certain Blood
and Tissue Flagellates”; Dr. W. A. Sodeman spoke
on, “Amebic Hepatitis”; Dr. N. F. Thiberge pre-
sented a paper on, “Is Oral Pollen Therapy De-
pendable”; Dr. T. A. Watters spoke on, “The
Future of Psychiatry in Medical Education.”

The following members had scientific exhibits at
the meetings:

Drs. Ernest Can oil Faust and Jos. S. B’Antoni,
“Certain Parasitic Infections of Military Import-
ance”; Drs. John R. Schenken and Emma S. Moss,
“Pathology of Malaria, Amebiasis, Histoplasmosis
and Mycetoma Pedis”; Drs. Vinvent J. Derbes and
Hugo T. Engelhardt, “The Heart in the Asthmatic
Child”.

Daniel J. Murphy, Secretary.

O

LOUISIANA STATE MEDICAL SOCIETY NEWS

CALENDAR

Society

East Baton Rouge

Morehouse

Orleans

Ouachita

Rapides

Sabine

Second District

Shreveport

Vernon

PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS

Date

Second Wednesday of every month
Second Tuesday of every month
Second Monday of every month
First Thursday of every month
First Monday of every month
First Wednesday of every month
Third Thursday of every month
First Tuesday of every month
First Thursday of every month

Place

Baton Rouge
Bastrop
New Orleans
Monroe
Alexandria

Shreveport

NEXT MEETING OF THE LOUISIANA
STATE MEDICAL SOCIETY

Be sure to note in the Organization Section
the date and the arrangements for the next meet-
ing of the State Medical Society in New Orleans.

BUY BONDS

Dr. P. T. Talbot has made all the arrangements
to purchase bonds for you in the present drive to
buy bonds. All you will need to do will be to drop
a postal card and the form will be sent to you.
Return it to the office of the State Medical Society,
1430 Tulane Avenue, New Orleans 13, with your
check and Dr. Talbot will buy the bond for you.

Incidentally, this will give the State Society credit
for their total allotment.

THE AMERICAN MEDICAL ASSOCIATION
MEETING

The next meeting of the American Medical
Association will be held in Philadelphia the latter
part of June. A change was made necessary be-
cause of the crowded conditions of the New York
hotels.

CHARITY HOSPITAL

At the annual meeting of the Charity Hospital
Visiting Staff held October 5 Dr. C. Gordon John-

Louisiana State Medical Society News

285

son was elected Chairman of the Staff, Dr. H. T.
Beacham, Vice-Chairman, and Dr. Frederick F.
Boyce, Secretary. These officers, together with
Drs, Adolph Jacobs and Eugene Countiss, are the
new members of the Medical Advisory Commit-
tee. Dr. G. C. Anderson and Dr. Frank Chetta
were elected to the Committee in 1943 for two-
year terms. Drs. Beacham, Countiss and Chetta
will serve as the Qualifications Committee for
1944-1945.

The Board of Administrators of the New Orleans
Charity Hospital has endorsed a plan by which all
applicants for admission would have radiographic
chest examinations, under the auspices of the Tu-
berculosis Control Section of the Louisiana State
Board of Health. The Hospital will furnish space
and the Board of Health will provide equipment,
supplies and technicians.

Dr. 0, P. Daly, Director of the Hospital, states
that the Hospital now has 73 internes, as com-
pared with 150 in July, 1941, 71 residents, as com-
pared to 170 as of that date, 200 members of the
Visiting Staff as compared with 440, and 206
graduate nurses as compared with 605.

SOUTHERN BAPTIST HOSPITAL

The regular monthly meeting of the Clinical
Staff of the Southern Baptist Hospital was held
on October 24. The program consisted of a dis-
cussion by Dr. John Adriani on Anesthetic Acci-
dents. Dr. Joe Wells presented the monthly death
report.

The regular monthly meeting of the Clinical
Staff of the Southern Baptist Hospital was held
on November 24, 1944, at 8 p. m. The entire pro-
gram was devoted to the death report presented
and discussed by Dr. William H. Gillentine.

TOURO INFIRMARY

The regular monthly meeting of the Medical
Staff of Touro Infirmary was held on November
8. The first presentation on the program was a
clinico-pathologic conference with a clinical dis-
cussion by Dr. Willard R. Wirth. Following the
conference Dr. Lucian Landry spoke on the sub-
ject of bilateral subclavian aneurysm and Dr. Sam
Nadler reported two cases of patients with tem-
poral headache. This paper was discussed by Dr.
Gilbert Anderson.

NEWS ITEMS

Dr. Edward L. Burns, Associate Professor of
Pathology and Bacteriology, Louisiana State Uni-
versity School of Medicine, is serving for several
weeks as Visiting Associate Professor of Pathology
at Washington University School of Medicine in
St. Louis.

Dr. Rupert Arnell, Professor of Obstetrics and
Gynecology, Louisiana State University School of

Medicine, was speaker at the November 6 meet-
ing of the Rapides Parish Medical Society in
Alexandria, Louisiana. His subject was “Prob-
lem of Therapeutic Abortions”.

Dr. John R. Schenken, Professor and Director of
the Department of Pathology and Bacteriology,
Louisiana State University School of Medicine,
spoke to the staff of Children’s Hospital, Mil-
waukee, Wisconsin, on Enterobius vermicularis,
November 9; to the Women’s Auxiliary of the Med-
ical Society of Milwaukee on November 10 on the
discovery of estrogens; and to the Medical Society
of Milwaukee County on November 10 on the re-
lationship of estrogens to cancer.

George B. Grant, former Major in the Medical
Corps, has been promoted to the rank of Lieutenant
Colonel. Lieutenant Colonel Grant is Executive
Officer of Base Hospital Number 24.

AMERICAN COLLEGE OF CHEST
PHYSICIANS

At the meeting of the Southern Chapter of the
American College of Chest Physicians, held con-
jointly with the Southern Medical Association at
St. Louis, November 13th and 14th, the following
doctors were registered from Louisiana: Major

Lloyd Ayers, De Ridder, La., Sydney Jacobs, New
Orleans, La.

The following officers have been elected by the
Southern Chapter of the College:

President, Alvis E. Greer, M. D., Houston, Tex-
as; First Vice-President, Carl C. Aven, M. D., At-
lanta, Ga.; Second Vice-President, Paul A. Turner,
M. D., Louisville, Ky., and Secretary-Treasurer,
Benjamin L. Brock, M. D., Waverly Hills, Ky.

AMERICAN FEDERATION FOR CLINICAL
RESEARCH

A two day meeting of the Southern Section of
the American Federation for Clinical Research is
being planned. The meeting will be held in Dallas
the latter part of January 1945.

Investigators wishing to present papers, please
submit an abstract of not over 200 words to the
Chairman, Dr. Alfred W. Harris, 812 Medical Arts
Building, Dallas 1, Texas, by January 1, 1945.

AMERICAN COLLEGE OF SURGEONS
Major General Charles R. Reynolds, M. C., re-
tired, former Surgeon General of the United States
Army, has been appointed as regent of the Ameri-
can College of Surgeons to be the Consultant in
Graduate Training in Surgery.

POLIOMYELITIS

The past year so far has been the worst year for
poliomyelities since 1916, at which time there were
reported 27,621 cases. In the first 41 weeks of this

286

Louisiana State Medical Society Neivs

year there were 16,133 cases. The most recent
serious epidemic occurred in 1931. The total num-
ber of cases for the whole year were not as great
as have already been reported for 1944. In Louis-
iana there were reported 147 cases up to the latter
part of October. The bulk of the epidemic has
occurred in seven states, New York, North Caro-
lina, Pennsylvania, New Jersey, Virginia, Ohio and
Kentucky.

UROLOGY AWARD

The American Urological Association offers an
annual award ‘not to exceed $500’ for an essay (or
essays) on the result of some specific clinical or
laboratory research in Urology. The amount of the
prize is based on the merits of the work presented,
and if the Committee on Scientific Research deem
none of the offerings worthy, no award will be
made. Competitors shall be limited to residents
in urology in recognized hospitals and to urologists
who have been in such specific practice for not
more than five years. All interested should write
the Secretary, for full particulars.

The selected essay (or essays) will appear on the
program of the forthcoming June meeting of the
American Urological Association.

Essays must be in the hands of the Secretary,
Dr. Thomas D. Moore, 899 Madison Avenue, Mem-
phis, Tennessee, on or before March 15, 1945.

ANNUAL FORUM ON ALLERGY
The Seventh Annual Forum on Allergy will be
held in the Hotel William Penn, Pittsburgh, Penn-
sylvania, on Saturday and Sunday, January 20-21,
1945. This is a meeting to which all physicians
are most welcome, and where they are offered an
opportunity to bring themselves up to date in this
rapidly advancing branch of medicine by two days
of intensive post-graduate instruction.

INFECTIOUS DISEASES IN LOUISIANA

The morbidity report of the Louisiana State De-
partment of Health showed that the week ending
October 14 was an unusual week in that there were
only four reportable diseases which exceeded 10
in number. These were diphtheria with 25 cases,
pulmonary tuberculosis with 19, hookworm infes-
tation with 14, and malaria with 13. The diph-
theria cases were scattered throughout the state,
no one parish having more than five. Of the un-
usual diseases there were two cases of typhus
fever. The succeeding week which closed October
21 was likewise a remarkably healthy week. Pul-

monary tuberculosis led the list of diseases that
occurred in numbers greater than 10 with 25 cases,
followed by 19 of hookworm infestation, 17 of
diphtheria, 16 of unclassified pneumonia, 12 of
scarlet fever, and 11 of malaria. There were three
cases of poliomyelitis reported this week and three
of typhus fever. Again the diphtheria cases were
scattered throughout the state. For the week which
closed October 28, diphtheria was still prevalent
throughout the state, 40 cases being listed, Tan-
gipahoa Parish having seven and no other parish
having more than five cases. Other diseases i'e-
corded in numbers greater than 10 include pul-
monary tuberculosis 32, unclassified pneumonia 19,
scarlet fever 15, and typhus fever 13. Six of the
typhus fever cases were reported from Calcasieu
Parish. During this week there were four cases
of poliomyelitis recorded in the office of the state
epidemiologist. For November 4, the figures in-
clude the venereal disease infections reported the
previous month. During the month of October
there were listed 1,587 cases of gonorrhea, 1,000
cases of syphilis, 47 of chancroid, and 24 of lympho-
pathia venereum. About half of the cases of gon-
orrhea were reported from military sources and
slightly over a tenth of the cases of syphilis. Of
the other diseases, non-venereal in etiology, that
were reported there was 16 cases each of malaria
and of scarlet fever. Fourteen of the cases of ma-
laria were reported from military sources. There
were listed also 26 cases of pulmonary tubercu-
losis, 17 cases of diphtheria, and 19 of unclassified
pneumonia. There was also recorded two cases
of poliomyelitis, both from the northern part of the
state.

HEALTH OF NEW ORLEANS

The Bureau of the Census, Department of Com-
merce, reported that for the week ending October
14 there were 136 deaths in the City of New Or-
leans, divided 77 white and 59 colored. Twenty of
these deaths occurred in children under one year
of age. This is a rather sharp increase from the
previous week in which the remarkably low figure
of 104 deaths were recorded. For the week which
closed October 21 the recorded deaths numbered
126. Eighty-two of these people who died were
white, 44 colored, and 10 were infants under one
year of age. The following week saw approxi-
mately the same figures as the one before. The 122
deaths listed this week took place in 77 of the white
population and 45 of the colored, with 12 infant
deaths. For the week ending November 4, there
was a very marked increase, 158 deaths being
listed, 100 of these deaths being in the white and
58 in the colored population, with only seven
deaths in children under one year of age. The
sharp increase in the death rate the previous week
was maintained the week ending November 11
when 156 deaths were recorded, divided 109 white,
47 colored, and 17 infants under one year.

Louisiana State Medical Society News

287

CORRESPONDENCE

Louisiana State Department of Veterans’ Affairs
Second Floor, Capitol Building
Baton Rouge, Louisiana

October 23, 1944.

Dr. Val H. Fuchs, President,

Louisiana State Medical Society,

1430 Tulane Avenue,

New Orleans 13, Louisiana.

Dear Dr. Fuchs:

You are probably familiar with the Louisiana
Department of Veterans’ Affairs, the new state
agency created by the 1944 Legislature, whose
services are devoted exclusively to the interests of
veterans of the armed forces and their families.

In carrying out the work of this department
there have come to our attention a number of in-
stances in which veterans of the first World War
had great difficulty in establishing their claims to
benefits because no careful record of their medical
histories had been kept by physicians from whom
they had received treatment.

Recognizing the possibility of a recurrence of this
condition with veterans of the present war, we are
endeavoring to take every precaution against it.
We want to make a personal appeal to all members
of the medical profession in Louisiana to keep a
thorough, accurate case history of every World
War II veteran applying for treatment.

We realize that it would be very difficult for us
to communicate this request to all of the state’s
many medical doctors; accordingly we should ap-
preciate your informing us as to whether your or-
ganization could bring our request to the indi-
vidual members of the profession, or if you might
recommend to us some practical method through
which we might reach them, ourselves.

With thanks for this cooperation, I am
Very truly yours,

Joe Darwin, Director.

To The Editor:

The recent editorials of the New England Jour-
nal of Medicine1 and the Journal of the American
Medical Association2 as well as the letter of Doctor
McGee to the New England Journal of Medicine3
strike a very important note at this time. Medical
certification has never before required more care-
ful thought on the part of the physician. With the
call of the armed forces for more ammunition par-
ticularly of the type produced by some of Louisi-
ana’s war plants, the doctors of this state should
feel keenly their part in keeping war workers on
the job.

The doctor, who occupies 'Such an important posi-
tion in the life of the community, is the person most
suited to issue certificates regarding the need of a
citizen for more meat .or more sugar or more shoes.
Likewise, the physician should be the one most
suited to certify that, because of his health, the
worker must have different hours or different work

or must even be placed in a different plant. For-
tunately most certification seen in this plant repre-
sents careful thought on the part of the doctor and
where there has been doubt in his mind he has re-
ferred the question of working conditions to the
medical department of the plant or to other suit-
able agencies. On the other hand, some of the let-
ters received at our plant demonstrate clearly that
the only indication for their issuance was the re-
quest of the employee.

Too often has an employee, unable to obtain the
type of release desired or because he has not had
just the type of work he wanted, presented him-
self at the personnel office with a letter stating
that this man must not work around chemicals.
Knowing little or nothing about the employee’s
woi’king environment, and being unwilling to find
out about it, the doctor took the easiest way out
and made a ridiculous generalization. That this
is not a local difficulty is made clear by the re-
ports of other plants throughout the nation. On
the contrary I think that we have had less cause
for complaint than most areas.

This responsibility, entrusted to us by society,
is great; and failure to realize it will reflect dis-
credit, not only on ourselves, but on our profession
as a whole. Let us not be involved in any scheme
of selfish individuals to avoid their duty through
false medical certification.

Shreveport, La.

James H. Eddy, Jr., M. D.

Medical Director,

Louisiana Ordnance Plant.

1. Medical Certification in Industry, editorial. New Eng-
land J. Med. 231:212 (Aug. 3) 1944.

2. Medical Certification and War Production, editorial,
J. A. M. A. 126:706 (Nov. 11) 1944.

3. McGee, L. C.: Industrial Medical Certification, New
England J. Med. 231:215 (Aug. 3) 1944.

KILLED IN ACTION
DR. L. SEXTON FORTENBERRY
(1908-1944)

The many friends of the much liked Captain L.
S. Fortenberry will hear with great sorrow of his
death in France, November 6. Dr. Fortenberry7
graduated from Tulane in 1934, and after his in-
ternship qualified himself by training at the Eye,
Ear, Nose and Throat Hospital for this particular
specialty. He went to Houma to practice and there
achieved great success in his chosen field. Be-
sides his wife, the former Mae Helen Bates, Dr.
Fortenberry leaves a son, Sexton, Jr., and a little
daughter, Betty Jewel.

IRVING HARDESTY

The many hundreds of students of Dr. Hardesty,
professor emeritus of anatomy at Tulane Univer-
sity, who retired in 1932, will learn of his death
with sincere sorrow. Dr. Hardesty was not only

288

Book Revieivs

a great teacher, but he was a splendid person in
every respect. The students admired him and liked
him because of his keen interest in their welfare.
Dr. Hardesty began his connection at Tulane in
1909, a total of 24 years.

DR. THOMAS LIPSCOMB ABINGTON
(1869-1944)

Dr. T. L. Abington was born in 1869, and was
graduated from The School of Medicine of Tennes-
see, Memphis, in 1901. He died at his home in
Oakdale on October 13, 1944. He was the son of
the late Dr. Thomas Welch Abing-ton, a graduate
of the School of Medicine of Tulane University.

DR. LOUIS T. DONALDSON
(1884-1944)

One of the active members of the State Medical
Society died November 4. Dr. Donaldson was born
in Reserve, Louisiana, August 9, 1884. He took
his premedical work at Jefferson College, Convent,

Louisiana, and graduated from the Medical School
of Tulane University in 1907. He moved to Hafan-
ville and conducted a practice for thirty-seven
years in this town and Jennings. Dr. Donaldson
will be missed by his many friends and associates
who appreciated his ability and his splendid char-
acter by electing him president of the Second Dis-
trict Medical Society.

DR. JAMES J. RYAN
(1879-1944)

Dr. James J. Ryan of New Orleans died on the
evening of November 24 at the Hotel Dieu. Dr.
Ryan graduated from Tulane University Medical
School and subsequently became professor of
anatomy at Loyola University. He was the chief
medical officer of the Loyola medical unit during
World War I. At the time of his death Dr. Ryan
was senior surgeon on the staffs of Hotel Dieu and
Mercy Hospital.

O

BOOK REVIEWS

X-ray Examination of the Stomach: By Frederic
E. Templeton, M. D., Chicago, The Univ. of Chi-
cago Press, 1944. Pp. 516 with 298 illus. Price
$10.00.

This volume is a rather complete roentgen study
of the pharynx, esophagus, stomach and duo-
denum. The value of films and the filming fluoro-
scope in addition to accurate and thorough fluoro-
scopic observation is stressed. The normal anat-
omy and physiology and the pathologic changes
produced by disease in the upper part of the di-
gestive tract are considered.

The discussion of the technic of examination is
thorough and the procedure is divided into four
stages. The information which should be obtained
in each stage or in each position of the patient
is covered in detail. The entire examination
should be conducted in an orderly and systemic
manner but special procedures are indicated when
the clinical or roentgen examination suggests the
necessity of such studies. Many helpful sugges-
tions are offered for the fluoroscopic examination
of obese patients with dim images of high and
posterior duodenal bulbs. The importance of the
rugal pattern and the technic of obtaining the
maximum information in the study of the mucosal
folds are considered.

The gastroscopic and roentgenologic findings
are correlated in the section on inflammation. The
use of compression and the filming fluoroscope
are valuable aids in the detection and demonstra-
tion of ulcer craters which may not be visualized
without these procedures. The differentiation of
the ulcer crater from the “false crater” requires

experience and a knowledge of the causes of
“false craters.”

The author divides neoplasms into mesenchymal
and epithelial tumors. The differential diagnosis
of the carcinomatous ulcer from the benign peptic
ulcer is discussed and many valuable suggestions
are offered.

The illustrations are excellent and the detailed
captions add considerably to their value. The
text is clear and the bibliography is adequate. This
volume may be recommended to anyone interested
in the upper digestive tract.

J. N. Ane, M. D.

Principles and Practices of Inhalational Therapy:

By Alvan L. Barach, M. D. Philadelphia, J. B.

Lippincott Company, 1944. Pp. 315, 59 illus.

Price $4.00.

The average physician uses inhalational therapy
to an ever-increasing extent in his practice. To
the well-established indication for oxygen therapy
in the pneumonias and in cardiac disease, there has
been added the use of carbon dioxide inhalations
for the various asphyxial states and, more re-
cently, the inhalation of helium-oxygen mixtures
for bronchial asthma and other states of respira-
tory tract obstruction. For these reasons, such
a book as Dr. Barac-h’s is a most welcome addition
to the practitioner’s library.

In this small and very well compiled monograph,
there are presented all the pertinent data for an
understanding of the value of inhalational therapy
as well as a good appraisal of the clinical implica-
tions. Each clinical entity for which some form

Book Reviews

289

of inhalational therapy may be useful is presented
in a separate chapter. There are several chapters
on the various types of apparatus in use today,
their operation and maintenance and the relative
advantages and liabilities. The chapters on the
anoxia occasioned by high altitudes are particularly
good for a basic understanding- of the problem
entailed in aviation, civilian or military.

Inasmuch as the majority of practicing physi-
cians will employ inhalational therapy at some time
or other in their professional careers, this book
may be strongly recommended. Dr. Barach, with
a background of extensive clinical experience and
intensive research, has brought together into a
very small space the data which are otherwise only
to be found by consulting a number of different
references. The text is well written, and through-
out the book major emphasis is placed on the
“practical” aspects.

Sydney .Jacobs, M. D.

Psychiatry and the Wav: Ed. by Frank J. Sladen,

M. D., Springfield, 111., Chas. C. Thomas, 1943.

Pp. 505. Price $5.00.

This particularly distinguished book gives a
very complete perspective of psychiatry out of the
experience and thought of its contributors who
participated in a conference on psychiatry at the
University of Michigan. It is a survey of psychi-
atry in which past experiences and technics are
examined, values are weighed, aims and goals are
reshaped, under the stress of war and wartime
conditions.

The thirty unusually fine papers and two sym-
posia, reported in the volume, represent the con-
tributions of some forty leaders in the special field
of psychiatry and its closely allied interests.

Everyone will find special concerns in its five
pai-ts. The Aim and Scope of Psychiatry pro-
gresses into the relations of psychology, pediatrics,
geriatrics, medicine and surgery. The Future of
Research and the Future in Psychiatry are topics
which introduce and close the second section. Psy-
chiatry in the Training, Experience and Education
of the Individual considers the problems of all age
groups in school and college, in family life, and in
the cities and communities. The crossroads of re-
ligion and, psychiatry are ably presented by a
clergyman of singular experience in the field of
medicine. The social aspects of mental illness are
adequately and interestingly covered. The sym-
posia summarize all aspects of the present war ef-
fort and post-war needs with special emphasis on
psychiatric considerations.

Eloquent and unmistakable are the teachings in
this splendid work and the employment of sug-
gested methods of approach to present problems
now would be as firm' a step as any that can be
taken toward preventing mental illness and at-
tempting to restore the minds of those who have

been injured in the present conflict as well as of
others.

C. P. May, M. D.

Malaria; Its Diagnosis, Treatment and Prophy-
laxis: By William N. Bispham, M. D. Baltimore,
Md., Williams & Wilkins, 1944. Pp. 198. Price
$3.50.

Malaria is probably having a more profound ef-
fect in the war in Asia and the Pacific than all
other diseases put together. It is therefore very
appropriate that this monograph should be issued
now. The author, or editor, is not quite clear
which he is, has managed to parade a very re-
markable array of reviewers which includes the
names of most of the leading authorities in the
United States — Simmons, Coggleshall, Melleney,
Craig, Taliaferro and Faust. In these circum-
stances, it is difficult to do anything but applaud
and one certainly has no difficulty in doing this
with a clear conscience. Nearly every chapter is
an excellent presentation of the subject — and it
is difficult to select any one for special comment.
Perhaps Dr. Coggleshall’s original contribution on
the presentation of malaria in West Africa merits
this, except that it is difficult to understand what
he means by ‘the obscure nature of the patho-
genesis and etiology of this disease (blackwater
fever) prevents the application of control meas-
ures that might reduce its incidence’. Surely, in
a blackAvater fever area, the elimination of mala-
ria will prevent blackwater fever.

The only other possible comment that could be
made on this excellent monograph is that the
‘authorities’ do not always exercise the authority
which they are entitled to do. For example, one
would not think it was worth while even mention-
ing the x-ray treatment of malaria, and certainly
not devoting a full page to Henry’s test, even to
question its value. Why not just ignore both?

In defense of two of his personal friends, the
reviewer questions whether it is fair to say that
“Blacklock and Macdonald believe that the in-
creased production of sarcolactic acid acuses black-
water fever.” The reviewer is quite sure that
neither has believed anything of the kind in the
last 15 years.

This book is the best recent monograph on ma-
laria and it should be read by all interested in
this important subject.

L. E. Napier, M. D.

Radiation and Climatic Therapy of Chronic Pul-
monary Tuberculosis: Edited by Edgar Mayer,
M. D., F. A. C. P., F. A. C. P., with the col-
laboration of 22 other contributors. Baltimore,
Williams & Wilkins Co., 1944. Pp. 398. Price
$5.00.

Dr. Mayer and his collaborators seek in this
treatise to show the physicians who fail to employ
heliotherapy and climatotherapy for the treatment

290

Book Reviews

of certain selected cases of chronic pulmonary
tuberculosis are overlooking- valuable means of
relief. Admittedly extra-pulmonary tuberculosis
is benefitted more in this way than is pulmonary
involvement, but evidence is presented to indicate
that heliotherapy will benefit the patient with
chronic fibrotic pulmonary tuberculosis.

Throughout the course of this book, emphasis is
placed on the clinical approach. It is stressed that
heliotherapy is only an adjuvant to the other,
more commonly accepted forms of therapy such
as the hygienic- dietetic regimen and collapse ther-
apy. At the same time, its use may be just enough
to turn the tide in the patient’s favor occasionally.

There is a general impression that heliotherapy
will soon be forgotten because extra-pulmonary
tuberculosis is fast disappearing. Dr. Mayer points
out that in some parts of Latin America today
and in post-war Europe, extra-pulmonary tuber-
culosis will be a very significant clinical problem.
For this reason, the physician who treats victims
of tuberculosis will be able to make good us of
heliotherapy in the immediate future.

This is a good reference book. There are short
chapters to outline the salient physical and phy-
siological factors entailed in heliotherapy and in
climatotherapy. Each indication for some spec-
ialized form of heliotherapy is discussed in a sep-
arate chapter which makes this book particularly
valuable to the physician who wants information
for a definite problem. The illustrations are well-
chosen and help to make the text useful.

Sydney Jacobs, M. D.

Surgical Disorders of the Chest; Diagnosis ancl
Treatment: By J. K. Donaldson, B. S., M. D.,
F. A. C. S. Philadelphia, Lea and Febiger, 1944.
Pp. 364, 127 illus. Price $6.50.

A book on surgical diseases of the chest is cer-
tainly needed because of the great advances which
have been made in this special field of surgery.
Dr. Donaldson’s work is an excellent resume of the
newer methods of treatment. It is a book that
could be utilized by every student of surgery and
since it is compact, it should be in every physician’s
library. A possible criticism of the book is that it
contains material which is not exactly applicable

to chest surgery, such as lipomata involving the
chest wall and melanoma. The book is profusely
ilustrated and contains an excellent bibliography.

Alton Ochsner, M. D.

Fundamentals of Internal Medicine: By Wallace
Mason Yater, A. B., M. D., M. S. in (Med.),
F. A. C. P. New York, D. Appleton- Century
Company, Inc., 1944. 2nd. Ed. Pp. 1286. Price
$10.00.

The reviewer has derived great pleasure in pe-
rusing the second edition of this textbook of in-
ternal medicine. Like the first edition, this book
continues to be a brief and accurate textbook in
the true sense of the word. Doctor Yater enlisted
the services of fourteen contributors in the prepa-
ration of this edition. There are several chapters
in the book which are not found in other current
standard textbooks on medicine, particularly the
chapters on Diseases of the Skin, the Ear, the
Eye, Dietetics, and Symptomatic and Supportive
Treatment. These are excellent additions to the
text. Another particularly useful chapter is that
concerning Clinical Values and Useful Tables.

All in all this book is highly recommended to
the student of internal medicine.

Roscoe L. Pullen, M. D.

PUBLICATIONS RECEIVED

Williams & Wilkins Company, Baltimore: A

Method of Anatomy, Descriptive and Deductive,
by J. C. Boileau Grant, M. C., M. B., Ch. B., F. R.
C. S. (Edin.)

Charles C. Thomas, Publisher, Springfield, Illi-
nois: A Bibliography of Aviation Medicine, Sup-

plement, by E. C. Hoff, D. Phil., B. M., B. Ch.,
Oxon, and John F. Fulton, M. D. Trichinosis, by
Sylvester E. Goult, M. D. The Biological Basis of
Individuality, by Leo Loeb.

Lea & Febiger, Philadelphia : Physiology in

Health and Disease, by Carl J. Wiggers, M. D., D.
Sc., F. A. C. P. Arthritis, by Bernard J. Comroe,
A. B„ M. D., F. A. C. P.

Reinhold Publishing Corporation, New York,
New York: The Art of Resuscitation, by Paluel
J. Flagg, M. D.

W. B. Saunders Company, Philadelphia and Lon-
don: Modern Clinical Syphilology, by John H.

Stokes, M. D., Herman Beerman, M. D., Se.D.
(Med.), and Norman R. Ingraham, Jr., M. D.

New Orleans Medical

and

Vol. 97 JANUARY, 1945 No. 7

THE DIAGNOSTIC AND THERAPEUTIC
POSSIBILITIES OF BRONCHOSCOPY*

GEORGE J. TAQUINO, M. D.t
New Orleans

In one sense it is almost unfortunate that
Chevalier Jackson and his associates have
been so eminently successful in the removal
of foreign bodies from the respiratory tract
by bronchoscopy. Any one who undertakes
to speak on this diagnostic and therapeutic
method is almost obligated to begin with
the statement that the bronchoscope was
originally devised for the express purpose
of removing foreign bodies and there are
still many physicians who regard its useful-
ness in the light of foreign body extraction
alone; but in spite of this popular concep-
tion the largest percentage of work done
in the Jackson Clinic is for bronchopul-
monary diseases. Bronchoscopy is not an
exceptionally heroic and dangerous pro-
cedure, but rather a simple and direct
means of investigation for the treatment
of bronchopulmonary diseases and for these
its possibilities are limitless.

It is regrettable that there has not been
a more general realization of, and therefore
a more general utilization of the diagnostic
and therapeutic possibilities of broncho-
scopy. Actually, as has been repeatedly
pointed out, bronchoscopy should be as in-
separably connected with bronchopulmon-
ary disease, and particularly with thoracic
surgery, as is cystoscopy with disease of
the genito-urinary tract and genito-urinary

*Read before the Orleans Parish Medical So-
ciety, New Orleans, June 12, 1944.

tFrom the Department of Otolaryngology, of the
Sch®ol of Medicine of Louisiana State University.

surgery. Data supplied by the one method,
just as data supplied by the other, may
sometimes determine the outcome of a given
case.

The chief reason for failure fully to uti-
lize the possibilities of bronschoscopy is en-
tirely erroneous but still a rather general
belief that it is a difficult and taxing and
dangerous procedure. In the early days,
when the only available tubes were very
primitive indeed, it might have been true, as
was once said of gastroscopy, that the use of
the method required “the eye of a hawk
and the instincts of a sword-swallower.”
But this is not true of modern instruments,
particularly when they are in the hands of
a properly trained practitioner.

Proper training, as Jackson and Jackson1
point out, implies training in a well organ-
ized bronchoscopic clinic, where the can-
didate must work for many, many hours
on the cadaver, the manikin board, and the
dog before he progresses to the human sub-
ject. Continued use of the method is then
necessary from the standpoint of improve-
ment of diagnosis. The removal of foreign
bodies from the tracheobronchial tree does
not make for proficiency in the diagnosis
of tracheobronchial and bronchopulmonary
disease. That can be achieved only by con-
stant observation of the manifestations of
those conditions.

As a matter of convenience to all con-
cerned, bronchoscopy is best carried out in
the hospital, but only a brief stay is re-
quired, and the procedure itself can be per-
formed in a matter of minutes in a properly
prepared patient (that is, one who has not
had food for five or six hours) , who is prop-
erly anesthetized with local agents, who is

292

Taquino- — Bronchoscopy

placed on the table in the proper position,
and in whom the investigation is conducted
by a competent team.-

It should be emphasized, however, that
bronchoscopy is not a substitute for a num-
ber of things, including a very careful his-
tory; a painstaking physical examination;
routine and sometimes special laboratory
examinations; examination of the nose and
throat, including tests of the swallowing-
reflex ; roentgenologic examination of the
chest, supplemented by bronchography ac-
cording to the indications; histologic ex-
amination of tissue removed by biopsy
through the bronchoscope; and bacterio-
logic examination of material aspirated
through the bronchoscope. Because of lack
of time I shall not be able to discuss this
phase of bronchoscopy in detail, I want to
emphasize at this point that the mapping
out of the lesions of the various broncho-
pulmonary diseases in which this mode
of investigation is indicated is a most use-
ful diagnostic aid, which should be em-
ployed far more frequently. The opaque
medium should be instilled under direct
fluoroscopic observation, after which films
which can be studied at leisure should be
taken.

Bronchography obviously requires a close
liaison between the roentgenologist and the
bronchoscopist. It has become a cliche to
say that it is

“ — the everlasting teamwork

Of every blooming soul.”

which makes bronchoscopy successful,1 but
it is obvious from what I have said that
nothing else can make it succeed.

The supplemental nature of bronchoscopy
is particularly apparent in connection with
roentgenologic examination, which is usu-
ally regarded as the final diagnostic word
in diseases of the chest. It is true that in
most instances the x-ray does demonstrate
the presence of pathologic changes. It is
equally true that many times it reveals only
their presence, but that their exact nature
remains obscure until bronchoscopy is car-
ried out. It is also true that if only bron-
choscopy could be employed earlier, it might

sometimes prove to be even more revealing
than roentgenologic examination would be
at the same period of the disease. One warn-
ing, however, should be issued : In broncho-
scopy, just as in many other diagnostic pro-
cedures, negative results are not necessari-
ly conclusive, and they should not be accept-
ed as such in the face of clinical evidence to
the contrary.

It is naturally impossible, in the limited
time at my disposal, to discuss all the diag-
nostic and therapeutic possibilities of bron-
choscopy. In addition to all forms of bron-
chial obstruction, of which foreign bodies
represent only one cause, indications for
the use of this method include cough,
dyspnea, hemoptysis, and purulent or muco-
purulent expectoration of obscure origins;
thoracic neoplasms; pulmonary abscess; as-
thma; tuberculosis; atelectasis; bronchiec-
lasis; and various miscellaneous indications.
Bronchoscopy is also useful, as already
pointed out, for the instillation of contrast
media for bronchographic purposes; for the
direct application of medications ; for the
aspiration of secretions; and occasionally
for the removal of neoplasms.

Bronchoscopy is not useful in all chest
conditions, and it is definitely contraindi-
cated under certain circumstances. It should
not be used in patients with cardiac disease
or aortic aneurysm. It contributes nothing,
and may do harm, in such conditions as pul-
monary embolism, pulmonary emphysema,
bronchitis, and bronchopneumonia, though
in recurrent or unresolved pneumonia, as
well as in persistent empyema, it may dem-
onstrate a causative bronchial or pulmon-
ary lesion, such as atelectasis or bronchiec-
tasis, which will explain the lack of response
to treatment. It has a limited field of useful-
ness in pulmonary tuberculosis. It should be
used with caution following acute inflamma-
tory reactions of the larynx, and when it
is used under such circumstances, prepara-
tions for immediate tracheotomy should al-
ways be made. When a repetition of bron-
choscopy is indicated, the second instrumen-
tation should be delayed until the reaction
from the first has completely subsided.

Taquino — Bronchoscopy

293

HEMOPTYSIS

Hemorrhage from the respiratory tract
is an excellent illustration of the light which
bronehoscopy can cast upon symptoms
whose origin is not always clearcut. In a
series of 435 cases studied by Jackson and
Diamond,3 eighteen different causes, which
frequently overlapped in the same case,
were revealed by this method, including
bronchiectasis in 138 cases, bronchiogenic
carcinoma in 82, tracheobronchitis in 74,
and pulmonary abscess in 51. The most in-
teresting thing about this series is that in
140 cases, including, it must be granted, 34
cases in which bronchoscopy also revealed
no positive findings, roentgenologic exami-
nation of the chest had revealed nothing-
helpful in diagnosis.

There is some difference of opinion as
to whether in such cases one should wait
for the subsidence of active hemorrhage be-
fore performing bronchoscopy. Usually a
delay is wise, since the cough reflex is abol-
ished by the local analgesic used, and the
possibility then arises that the patient may
drown in his own blood. If bleeding should
recur when the tube is in place, the best
plan is to leave it in situ and remove the
blood by suction, since, as noted, the cough
reflex cannot be relied upon.

THORACIC NEOPLASMS

In recent years there has been a striking
increase in the incidence of carcinoma of
the lung. Quite aside from the etiologic con-
siderations which probably account for
some of the increment, a large portion is
undoubtedly accounted for by the increased
frequency of diagnosis. Once made only at
autopsy, diagnosis is now made relatively
often during life, largely as the result of
bronchoscopic examination. In the series of
cases reported by Jackson and Diamond,
pneumonectomy was feasible in only one of
the 82 cases of hemoptysis due to bronchio-
genic carcinoma, which is most depressing,
but to be expected, for hemoptysis is a late
symptom of this disease. On the other hand,
90 per cent of the tumors were located in
major bronchi, which is most encouraging,
for it means that if only patients with this
disease can be seen early enough, radical

excision of the neoplasm will be possible in
the majority of cases. It has been estimat-
ed that by the employment of broncho-
scopy a correct diagnosis is possible in 75
per cent of all cases, and it is known that
on the average patients thus investigated
live two and a half times as long as those
in whom this procedure is not carried out,
obviously because therapy is instituted ear-
lier. If this method is employed with refined
roentgenologic methods, based on the inter-
pretation of moderate or minimal degrees
of bronchostenosis, the outlook becomes
even more hopeful.4

There is little hope, however, for the
patient who is not investigated until he-
moptysis and other late symptoms develop.
In bronchiogenic carcinoma the suspicion
of malignancy is the first step on the road
to salvation from death. Results will not
be materially improved until bronchoscopy
is carried out on suspicion, which means
while the patient is still presenting symp-
toms such as cough, dyspnea, asthmatic
wheezing, and a sense of pressure in the
chest. These symptoms, if they are per-
sistent and if their origin is not clear,
should always call for bronchoscopic exam-
ination. They are the manifestations of
many diseases of no consequence, but they
are also manifestations of bronchiogenic
carcinoma while it is still in its early, cur-
able stages.

Bronchoscopic examination permits the
distinction, which roentgenologic examina-
tion does not, between malignant and be-
nign neoplasms. Punch biopsy permits the
same distinction, but it is feasible only in
the occasional superficially located tumor,
and it may be associated with considerable
risk. Bronchoscopic examination, more-
over, gives far more exact information as
to the possibility of surgical excision of
the growth than does either of these meth-
ods, and makes clear, as neither of the oth-
ers does, whether a suitable stump will be
available if pneumonectomy or lobectomy
is decided upon.

From 75 to 90 per cent of tumors proved
to be benign can be removed through the
bronchoscope, but this is neither a rational

294

T AQUINO — Bronchoscopy

nor a possible method when the tumor is
malignant, though in an occasional very
early case pneumonectomy shows that bi-
opsy carried out at bronchoscopy has ac-
tually removed the entire malignant
growth. If the tumor is inoperable, pallia-
tive bronchoscopic procedures may add
greatly to the patient’s comfort. Removal
of the accessible obstructing growth, for
instance, and aspiration of retained secre-
tions will permit better aeration and relieve
toxicity. The application of radon seeds
through the bronchoscope is also possible,5
but the results of this method naturally de-
pend upon the accessibility of the tumor
and upon its properties of radiosensitivity
or radio-resistance.

LUNG ABSCESS

A great many cases of lung abscess
could be prevented if bronchoscopy were
carried out before the removal from the
operating room of every patient who has
vomited in the course of operation. Every
bronchoscopist knows that, for every bron-
choscopist has had the experience, in both
acute and chronic lung abscess, of remov-
ing from it vomitus, blood, and bits of tis-
sue.

Adequate drainage is the most important
single factor in the therapy of lung abscess.
If it can be achieved by postural methods,
so much the better. If it cannot be, bron-
choscopic drainage should be given a fair
trial before surgery is carried out. Even
if surgery must eventually be resorted to,
bronchoscopy is still useful. It demon-
strates the extent of the abscess and the
best method of approach to it, a piece of
information which sometimes determines
whether the patient is to live or to die. It
is a wise plan, immediately before the ab-
scess is opened, to aspirate all visible secre-
tion through the bronchoscope; the more
distal bronchi can be fairly well cleared if
the patient coughs at intervals during the
process.

After the abscess is opened, the use of
the bronchoscope may limit the spread of
infection and save the patient from drown-
ing in his own secretions.

ASTHMA

Although the pathologic basis of asthma
was once supposed to be spasm, it is a curi-
ous fact that spasm has never been dem-
onstrated in any reported case studied by
bronchoscopy. The thick, gelatinous, tena-
cious, membranous secretion which is fre-
quently thus revealed makes clear the
source of the patient’s respiratory distress,
and also explains why sedation, antispas-
modics, and inhalants are so often without
effect. Removal of the obstructing secre-
tion by the bronchoscope is the obvious ex-
planation of relief in some cases, but the
relief usually occurs too promptly to make
removal of bacteria or toxic substances any
part of the explanation, though the ulti-
mate result of their elimination is naturally
good. In some instances in which such se-
cretions are not present, but in which re-
peated passage of the bronchoscope is cura-
tive, there is no explanation for the pa-
tient’s relief, though a psychic effect can-
not always be discounted. Naturally a
great deal of benefit cannot be expected in
asthma which is on a proved allergic basis.

TUBERCULOSIS

Bronchoscopy has a useful field in tuber-
culosis, and in the opinion of some observers
that field is constantly being extended.6
The long-accepted idea that a cavity in the
upper lung is tuberculous and a cavity in
the base is not, is not invariably true;
bronchoscopy often reveals tubercle bacilli
in many supposed pyogenic abscesses, and
diametrically alters the plan of treatment.
The diagnosis of pulmonary tuberculosis
can also be made by this method in cases
in which neither roentgenologic examina-
tion nor repeated examination of the spu-
tum has been helpful.

Bronchoscopy should be carried out be-
fore any surgery of pulmonary tuberculosis
is undertaken, to determine the full extent
of the disease. It is well to carry it out
after thoracoplasty or pneumothorax when-
ever the sputum continues positive, as the
collapse may be incomplete, and, if left un-
treated, may set up the nucleus of a later
abscess. Surgery is useless if extensive
tracheobronchial disease exists.

Taquino— Bronchoscopy

295

Useful as is the method, however, it
should be used only on indications. It should
be employed with discretion, if at all, in
patients who have had recent hemoptysis
and patients with marked debility. It had
best be omitted in cases of healed laryngeal
tuberculosis, in which it may cause a reac-
tion, and special care is necessary in cases
in which there is a high concentration of
tubercle bacilli in the sputum.

Bronchoscopy is not of great therapeutic
value in tuberculosis. Cauterization of a
localized granuloma in the lower trachea
sometimes prevents asphyxia, but such
lesions are unusual. The more common
form of granuloma, which fills the main
bronchus from the introitus down to the
lower lobe, is best left alone, both because
only a portion is accessible and because lo-
cal therapy may interfere with spontaneous
healing, which frequently occurs. The as-
piration of retained secretions as the re-
sult of bronchiectasis beyond areas of par-
tial obstruction is of only temporary value,
since such secretions reaccumulate within
a few hours.

BRONCHIAL OBSTRUCTION

Bronchoscopy has an almost limitless
field of usefulness in any form of bron-
chial obstruction, whatever the cause. As
Jackson and Jackson have pointed out, the
diagnosis of asthma should never be made
in a child until the presence of a foreign
body has been excluded by this method. In
the early stages of tracheobronchial diph-
theria pulpy masses may obstruct the bron-
chi, and later, membranous casts may ac-
tually cause asphyxia, for which tracheo-
tomy is not helpful.

A patient who develops atelectasis after
operation may recover without treatment,
but he may also die, even in an oxygen tent,
if the cause of his obstruction is not prompt-
ly relieved. Furthermore, patients who
eventually recover without treatment are
likely to develop chronic pulmonary suppur-
ation. Incidentally, there are few things
more dramatic in medicine than the prompt
recovery after bronchoscopy of a patient

who has seemed almost moribund from mas-
sive atelectasis.

MISCELLANEOUS CONDITIONS

In bronchiectasis, as Jackson and Jack-
son have pointed out, bronchoscopy has
demonstrated the existence of a “septic
tank,” and aspiration by way of the bron-
choscope has proved itself the most satis-
factory method of relieving it. Surgery is
frequently required in extensive and long-
standing bronchiectasis, but when for any
reason it is contraindicated aspiration adds
materially to the patient’s comfort. It is
also a useful adjunct measure in prepara-
tion for operation. Aspiration of secre-
tion in a weakened pneumonia subject,
whose cough reflex shares in his general
weakness, may prevent later bronchiectasis.

Other bronchopulmonary states in which
bronchoscopy is useful,7 chiefly as a method
of differential diagnosis, include bacterial
and mycotic diseases such as leptothrix
and ectinomycosis ; syphilis; angioneurotic
edema; spirochetosis; phrenic nerve pa-
ralysis ; any disease in which there is a de-
viation from the usual course.

Bronchoscopy is sometimes useful in di-
lating bronchial strictures of various orig-
ins, but thick strictures, such as occur in
tuberculosis, with associated destruction of
the bronchial cartilages, are best left un-
treated.

SUMMARY

1. The various indications and contrain-
dications for bronchoscopy are outlined.

2. This method has a wide field of diag-
nostic usefulness, and a more limited field
of therapeutic usefulness.

3. A more general employment of bron-
choscopy would produce better results in
various bronchopulmonary diseases, and it
is unfortunate that the opinion, which is
entirely contrary to fact, still prevails that
its chief field of usefulness is in the re-
moval of foreign bodies.

REFERENCES

1. Jackson, Chevalier, and Jackson, Chevalier L. :
Bronchoscopy, Esophagoscopy and Gastroscopy. A Manual
of Peroral Endoscopy and Laryngeal Surgery, ed. 3, Phila-
delphia and London. W. B. Saunders Company. 1934.

2. Tucker, Gabriel : Bronchoscopy, in Ballenger, W. L..

and Ballenger, H. C. : Diseases of the Nose, Throat and

296

T AQUI N 0 — B ranch oscop y

liar. Medical and Surgical, ed. 7, Philadelphia. Lea & Fe-
biger, 1938, p. 943.

3. Jackson, C. L.. and Di a mend , Sidney : Hemorrhage

from the trachea, bronchi and lungs of non-tuberculous
origin, Am. Rev. Tuberc., 45 :126. 1942.

4. 1 aquino. G. .1. : The value of bronchoscopy in bron-

chiogenic carcinoma. New Orleans M. A S. .1.. 91 1939.

5. Taquino. G. .T. : The bronchoscope as an aid in

diagnosis and treatment, Tr. Am. Laiyng., Rhin. & Ootol.
Soc., 1936, p. 519.

6. Myerson. M. C. : Tuberculosis of the Ear. Nose, and

I liroat, Including the Larynx, the Trachea, and the P.ron-
chi. Spring-field and lialrimore. Charles ('. Thomas, 1944.

i. K lamer, i l lido] p h ; Symposium on Peroral Endoscopy.
Indications for direct laryngoscopy and bronchoscopy.
Laryngoscope, 49:1168, 1939.

DISCUSSION

Dr. Louis A. Monte (New Orleans): Dr. Ta-
ti11'110 has, in a necessarily brief presentation, giv-
en us a comprehensive coverage of the large and
growing field of bronchoscopy. As the x-ray to-
day is indispensable in the study of bronchopul-
monary diseases so shall the bronchoscope come
more and more into popular use in this field.
Bronchoscopic examination in skillful hands is
non-traumatic — the idea of mucosal injury with
secondary infection or bronehiogenic spread by in-
terfering with nature’s defense walls has been
proved nonimportant. Cystoscopic- and procto-
scopic examinations are familiar and upon any
suspicion are without hesitation used on our pa-
tients. Bronchoscopic differs only in an anatomic
fashion since all the procedures are truly a part
of the physical examination, namely, inspection.
When the therapeutic value of the bronchoscope
is added to that of diagnosis we have at our com-
mand a really potent weapon toward combating
the many disturbed states occurring in the respira-
tory tree.

While admitting that a thorough history and
physical are the basic foundation of the patient’s
examination, it should also be remembered that to
omit any procedure that might prove or disprove
our suspicions is a serious omission. Besides the
absolute indication of bronchoscopy in foreign
bodies its general use or indication is in those ob-
scure pulmonary conditions which by their general
nature often defy recognition by the usual meth-
ods of study.

The study of 436 hemorrhage cases by Jackson
and Diamond as quoted by Dr. Tajuino is inter-
esting in that it very forcefully stresses the im-
portance of thorough bronchoscopic study in pa-
tients with hemoptysis otherwise unexplained.
Whereas the x-ray proved helpful in diagnosis in
68 per cent of the cases, the use of the broncho-
scope raised the percentage diagnosed to 91 per
cent, an increase of 23 per cent.

The value of bronchoscopy in tuberculosis is as
the author states, mainly that of proper evaluation
of cases relative to contemplated collapse meas-
ures. At this point it is well to give .’ue credit to
the bronchoscopist. Pathologically, tuberculous

tracheobronchitis was recognized a century ago.
Yet it has been only in the last decade that its
clinical significance has been recognized and be-
come a definite factor in the proper management
of pulmonary tuberculosis. To the bronchoscopist
most of this progress must be attributed. Also of
value in a large tuberculosis service, such as the
Dibert where all patients suspected of having tu-
berculosis are sent to the observation ward, the
bronchoscope will reveal other non-tuberculous dis-
eases such as carcinoma, bronchiectasis, fungus
diseases, foreign bodies, etc. Though relatively
few in number, these patients are spared a useless
stay in a tuberculosis service.

It is difficult to pass on without saying a few
words about cancer of the lung. While as Dr. Ta-
quino stated there is probably a real increase in
the incidence of neoplasms, the chief factor in this
increase is most likely the improvement in our
diagnostic acumen. It is interesting to note that
in our day a patient need not die and have an
autopsy before lung tumors are diagnosed. The
increasing recognition of this condition in life
seems to have paralleled the more general use of
the bronchoscope. As with most serious chronic
diseases, the earlier lung tumors are suspected
and proved, the more valuable and beneficial will
be the help offered by the surgeon. Toward this
goal the bronchoscopist must by necessity lead the
way. Concerning lung punch biopsy I recall a re-
cent patient in whom the diagnosis from the stand-
point of the history, physical examination and
x-ray study was between one of two conditions,
namely, cancer and tuberculosis. A bronchoscopic
examination failed to visualize any direct evidence
of pathology though by the aid of lung mapping
there was shown to be some failure to fill the up-
per left lobe bronchus. The serial x-ray films dem-
onstrated a fairly rapid spreading homogeneous
opacity which extended to the very periphery. This
indicated diffuse infiltrative pathology through
lung tissue, so a punch biopsy was thought safe
and was performed without harm to the patient.
A mixture of blood and necrotic-like tissue was
aspirated and the pathological report was that of
adenocarcinoma.

The use of bronchoscopic examination in unre-
solved pneumonia raises the question as to the ex-
istence of any such condition. While it is true that
the speed of resolution is often delayed, many
authorities believe any undue chronicity is based
on some other underlying cause, this cause being
in most cases a varying degree of bronchial ob-
struction such as that produced by secretions,
gland adenopathy, carcinoma or non-opaque for-
eign body, and it is this obstruction that accounts
for distal bronchopulmonary changes. If this
viewpoint of unresolved pneumonia be correct then
bronchoscopy is an indicated procedure.

Since all patients presenting signs or symptoms
of bronchial obstruction require bronchoscopic ex-
amination it might be well to direct our attention

Taquino — Bronchoscopy

297

to the so-called asthmatic bronchitic individual.
This is the patient having no previous allergic his-
tory who upon or soon after developing an acute
tracheobronchitis presents the usual asthmatic
wheezing. The response to usual medications is
not always gratifying and for awhile we are con-
fused as to the true etiology. These cases should
more accurately be diagnosed as active tracheo-
bronchial infection in which will be found a swoll-
en mucosa and a lumen containing much thick te-
nacious secretion. Bronchoscopic drainage, shrink-
age and lavage will in most cases afford much
benefit.

Finally. I would like to repeat Arbuckle’s words
by saying that bronchoscopic examination is only
a means of improving that part of the physical
examination known as inspection, either directly
or indirectly, and by so increasing the value of in-
spection we decrease our guessing.

Dr, F. E. LeJeune (New Orleans) : I enjoyed
Dr. Taquino’s paper very much. He has aptly
brought out how bronchoscopy, in its inception,
was used entirely for removal of foreign bodies.
Many lives have been saved by that procedure and
many in the future will be saved by skillful re-
moval of foreign bodies. However, the scope of the
usefulness of bronchoscopy has increased to in-
clude the diagnosis and therapeusis of many tho-
racic conditions.

Years ago when I first started practicing oto-
laryngology, I performed bronchoscopy only for
removal of foreign bodies. Now, I do only a small
percentage for this purpose. I believe that in the
future bronchoscopy will be used more and more
as a diagnostic and therapeutic measure. Since I
am closely associated with a surgeon who does a
great deal of thoracic surgery, I have seen many
cases requiring bronchoscopy for treatment. My
percentage of accurate diagnoses is much lower
than the 75 per cent which Dr. Taquino mentioned
he was able to make in neoplasms of the chest. I
have not been able to make an accurate diagnosis
in that high a percentage of cases because fre-
quently a neoplasm is in the upper lobe of the
bronchus. Visualization is impossible unless the
lesion protrudes to the mouth of the upper lobe of
the bronchus because it is impossible to see around
the corner through the bronchoscope. If we can-
not actually visualize the growth itself, many
times we must make the diagnosis by study of
the walls of the bronchi. An examination of the
contour, flattening of the wall, appearances of in-

filtration and change in color, are significant. Fre-
quently we have made the diagnosis, in spite of
the fact that we could not prove it, by removing a
piece of tissue for microscopical examination.

The preoperative bronchoscopic examination in
cases of large abscesses and neoplasm of the lung
is important, and postoperative bronchoscopies and
aspirations are even more important. I would like
to cite one case. A lung was removed because of
a tumor on one side in a patient in whom multiple
lung abscesses had developed as a result of a neo-
plasm in the middle lobe of one lung. Following
closure of the wound, search was made for that
neoplasm. It was not found. Meanwhile, I was
doing a bronchoscopic aspiration and found the
tumor lodged in the proximal part of the right
main stem of the bronchus. The tumor was free.
Certainly, if the patient had been sent back with
that tumor, nearly as large as a marble, it would
have been dislodged from its place in the right
bronchus and trachea, causing asphyxiation and
death. The removal of the tumor piece-meal was
accomplished through the bronchoscope, as it was
too large to remove in toto. Aspiration, particu-
larly in cases of lung abscess, where purulent ma-
terial is spilled by the handling of the lung being-
removed, is important. Purulent material is
squeezed out and enters the other lung and unless
aspiration is performed the postoperative results
may be poor.

Dr. Taquino has aptly brought out that broncho-
scopy of the future promises a great deal to the
thoracic surgeon and internist.

Dr. L. W. Alexander (New Orleans) : I thor-
oughly enjoyed Dr. Taquino’s paper. There is only
one point to bring out which was not touched
upon; that is expiration of trachea after tonsil-
lectomy where there is large amount of bleeding.
I think that is very important and I think when-
ever a patient has had an excessive amount of
bleeding from the throat he should have laryngeal
examination after operation to be sure there is no
blood left in the tracheal bronchial tree.

Dr. George Taquino (in closing) : Dr. Alexander
brought out a very interesting fact when he said
that following tonsillectomy careful examination
of the tracheal bronchial tree should be made. I
would say that in almost every case of tonsillec-
tomy you will find blood in the trachea if you look
for it.

Bronchoscopy is only part of the scheme of the
practice of medicine. Unless we can pool our
knowledge, that is the knowledge of the thoracic
surgeon, roentgenologist, and internist, and path-
ologist, bronchoscopy alone would probably be a
failure. With the combination of all and pooling
of knowledge we can arrive at very valuable con-
clusions and in many instances be of great assist-
ance in saving many a patient’s life.

298

LeJeune — Carcinoma of Larynx

CARCINOMA OF THE LARYNX*

FRANCIS E. LeJEUNE, M. D.t
New Orleans

That great surgeon, George Crile, has
aptly said that no surgical procedure offers
so certain and permanent a cure as chat
for intrinsic cancer of the larynx, provided
an early diagnosis has been made. All
laryngologists concur in this statement;
however, the way to obtain an early diag-
nosis remains the most baffling problem.
Fully 40 per cent of the patients with
carcinoma of the larynx who consult the
laryngologist for the first time have such
advanced lesions that little or no surgical
procedure can be offered them. It is de-
plorable that these patients are doomed
because of their delay in consulting a laryn-
gologist. This delay is not deliberate but
rather the result of ignorance of the seri-
ousness of the existing conditions within
the larynx. Unfortunately, intrinsic can-
cer of the larynx does not produce any pain
or other discomfort in its early stages. For
this reason, the patient is reluctant to con-
sult a laryngologist merely because of the
existing hoarseness, since in the past many
similar conditions have cleared up spon-
taneously. We have all experienced hoarse-
ness following an ordinary common cold
and because of the spontaneous recovery
we have come to consider it a trivial symp-
tom. Unfortunately, this is not always true
and we are forced to the definite conclusion
that any patient with hoarseness lasting
over a period of two weeks deserves and
should have a mirror examination of the
larynx. Frequently, this simple procedure
will permit the early diagnosis of tubercu-
losis, syphilis, cancer and other pathologic
conditions existing within the larynx, many
of which are amenable to treatment in the
early stages.

It would seem that the incidence of can-
cer is increasing or else our modern meth-

*Read before the meeting of the Orleans Parish
Medical Society in New Orleans, June 12, 1944.

t From the Department of Otolaryngology, Tu-
lane University School of Medicine and the Sec-
tion on Ear, Nose and Throat, Ochsner Clinic, New
Orleans.

ods of diagnosis permit the more frequent
recognition of this disease. Cancer now
ranks as the second most frequent cause
of death in this country, being surpassed
only by heart disease. About 4 per cent of
all malignancies of the human body occur
in the larynx and about 94 per cent of these
lesions are found in men. The reason for
the great preponderance of carcinomas of
the larynx in men is still unknown.

Eighty-five per cent of laryngeal lesions
involve one vocal cord or ventricular band
and are spoken of as intrinsic carcinomas.
The remaining 15 per cent, which occur on
the rim or posterior portion of the larynx,
are known as extrinsic carcinomas. The
importance of this classification is more
fully appreciated when it is realized that
the intrinsic type of cancer of the larynx
responds favorably to surgical intervention,
whereas in the extrinsic type the prognosis
is poor. In contrast to the predominance
of intrinsic laryngeal carcinomas in males,
it is interesting to note that extrinsic carci-
nomas occur with more frequency in
women.

In laryngeal cancer, as is now the con-
ception in all malignancies, there is no defi-
nite age incidence. The larger percentage
of cases occur between the fourth and sev-
enth decades of life with the highest inci-
dence in the sixth decade, although the
growth is occasionally encountered in
younger persons. A laryngofissure was re-
cently done on a twenty-one year old boy
and a laryngectomy on a twenty-eight year
old man. Cases of younger patients have
been reported.

The etiologic factor in cancer of the
larynx, as in all cancers, is not definitely
known. Irritants predispose a delicate
mucosa to malignant changes. Smoking
has been considered to act as an irritant to
the laryngeal mucosa, yet we have seen sev-
eral patients with carcinoma of the larynx
who have never used tobacco in any form.

In its incipiency intrinsic cancer of the
larynx is always unilateral, of slow growth
and late extension because of the -peculiar
and restricted lymphatic arrangement with-
in the larynx. The preferential site is that

LeJeune — Carcinoma of Larynx

299

region which is most active, the vocal cord ;
Jackson estimates 85 per cent of carci-
nomas are found on this organ. Because
of the limited extension of the lymphatics
within the region of the cords, the prog-
nosis is good in all early intrinsic lesions.
Intrinsic carcinoma of the larynx offers a
larger percentage of cures than carcinomas
occurring in any other organ of the body,
if an early diagnosis has been made.

Similarly, no other organ in the body
gives as early a warning of the presence
of malignancy as does intrinsic carcinoma
of the larynx. Practically with its incep-
tion, intrinsic carcinoma of the vocal cord
produces an alteration of voice recognized
as hoarseness. This manifestation will
persist and gradually become worse as the
lesion slowly increases in size. There is
absolutely no pain or discomfort in the
early stages of the disease. Laryngeal ex-
amination is imperative in every case of
persistent hoarseness for this is the only
manner by which an early diagnosis can
be made. The importance of an early ex-
amination cannot be stressed too vigorously
as the very life of the patient depends en-
tirely upon early recognition of the disease.
The general practitioner is in a position to
play an important role in the recognition
and control of intrinsic cancer of the
larynx. He must, however, be on the alert
for cases of persistent hoarseness, refer-
ring these to a competent specialist who
will conduct a thorough laryngeal investi-
gation. Th,e cooperation of the general
practitioner is necessary in disseminating
to the patient the fact that persistent
hoarseness is the danger signal in carci-
noma of the larynx. Until the layman be-
comes fully cognizant of the significance of
persistent hoarseness, we cannot expect to
see more cases of malignancy of the larynx
in the early stages.

It is unfortunate that so many cases of
carcinoma of the larynx seen for the first
time by the laryngologist are so far ad-
vanced that little or nothing can be offered
them. These advanced cases would never
be seen if a routine examination were made
early in all cases of persistent hoarseness.

If an early diagnosis were made in every
case of carcinoma of the larynx and proper
measures instituted, there would be com-
paratively few cases in which complete ex-
cision of the larynx would be required. In
most cases a tentative diagnosis can be
made following mirror laryngoscopy. Be-
cause it is at times difficult to distinguish
between the lesions of carcinoma, syphilis
and tuberculosis, surgical procedures on
the larynx should never be attempted until
a biopsy, or repeated biopsies, when neces-
sary, have been performed.

By far the most frequent lesion encoun-
tered in the larynx is a squamous cell car-
cinoma, which in the early stages is always
unilateral. Eighty-five per cent of these
occur on the vocal cord and usually grow
slowly because of the restricted lymphatic
Supply. The lesion generally extends in the
longitudinal plane of the cord. As soon as
it becomes manifest on the cord, a warning
signal develops in the form of hoarseness.
This hoarseness is persistent and its sig-
nificance should be recognized early. Ample
time for study, diagnostic confirmation and
surgical intervention is thus provided by
nature. Delay in examination not only per-
mits progression of a serious lesion unmo-
lested, but also permits extension of the
lesion to a stage whereby little can be done
for the patient.

Whereas intrinsic cordal carcinomas give
early warning of their presence, lesions oc-
curring on the aryepiglottic folds, or the
outer rim of the larynx give no indication
of their existence until they are fairly well
advanced. This latter type of lesion repre-
sents the extrinsic carcinoma which pre-
sents a much less favorable prognosis than
the intrinsic type. As a rule, the first
symptom presented by extrinsic lesions is
local discomfort and pain or deglutition.
These do not manifest themselves until
rather late; consequently, the lesions are
always fairly well advanced when first
seen.

Once the diagnosis has been established,
the proper surgical procedure must be car-
ried out. The amount of surgical interven-
tion necessary to effect a cure in carcinoma

300

LeJeune — Carcinoma of Larynx

of the larynx is directly proportionate to
the extent of the lesion. For this reason,
an arbitrary division of the cases into four
groups will facilitate the discussion of
treatment.

The first group, representing the earliest
and most definitely limited of all the lesions
encountered, comprises carcinomas con-
fined to a small portion of the surface of
one vocal cord. The tumor may be only
the size of a grain of rice, a match head or
a pea, but it is essential that normal tissue
exist on all sides. Such a lesion is generally
seen somewhere near the junction of the
anterior and middle thirds of the vocal
cord. Thus it can readily be seen that this
group includes only a very special type of
growth which unfortunately is not seen
often enough because of delay in otolaryn-
gological consultation. Intralaryngeal ex-
tirpation with wide margins of normal tis-
sue offers much to these patients. The per-
centage of cures in this group is equally as
high as in group two where the surgical
procedure is more formidable. This method
is simple, accurate and productive of vocal
and end results superior to any other sur-
gical procedure for carcinoma of the
larynx.

The second group includes those cases of
early cancer of the vocal cord which are
either too far advanced or too unsatisfac-
torily located for operation by intralaryn-
geal dissection and yet offer reasonable
hope of cure without the necessity of total
extirpation of the larynx. The ideal case
is one in which the lesion involves the mid-
dle portion of the vocal cord with both ends
uninvolved. The operation of laryngofis-
sure, which through an external approach
is directed toward splitting the thyroid car-
tilage in the median line, thereby exposing
its interior, is a brilliant technical concep-
tion and is relatively simple to perform.
The results are excellent and the voice fol-
lowing operation is usually very good. More
and more cases are being seen which fall
into this group and the benefits obtained
from such an operation merit its continued
use.

Into the third group are placed those
cases in which the lesion, although consid-
ered too extensive foor laryngofissure, is
still confined within the cartilaginous struc-
ture of the larynx. Total laryngectomy is
indicated in this group, provided there is
no evidence of cervical metastasis. In the
presence of an extensive cancer there can
be no compromise; partial loss of voice is,
of course, preferable to the loss of life.
Laryngectomy provides excellent results in
properly selected cases, that is, those in
which the lesion is still confined within the
larynx proper. The performance of laryn-
ectomy is long and tedious and is best done,
in our opinion, under heavy sedation and a
local anesthetic.

For the past thirteen years I have used
the mid-line incision extending from above
the hyoid bone to the suprasternal notch.
This type of incision facilitates closure and
expedites healing so that the patients are
out of bed on the fifth day, at which time
the feeding tube can also be removed. De-
tails of the operative technic will not be
discussed here, as this would be of interest
only to laryngologists. It is my policy, be-
fore doing a laryngectomy, to attempt a
short period of training during which the
patient is taught to swallow and belch air
from the esophagus. This greatly facili-
tates and shortens that trying postopera-
tive period when the patient is again learn-
ing to talk. The rapidity with which these
patients develop a voice and the excellent
quality of their voices is astounding. This
is far preferable to the use of an artificial
larynx.

My observation is that laryngeetomized
patients accept the problem of rehabilita-
tion in a calm and determined manner, and
in spite of their handicap they ai’e a happy
lot, thankful to be alive and anxious to do
their bit in this world today. To date 81
laryngectomies have been done with no op-
erative mortality. There have been some re-
currences, principally cervical metastasis,
but 85 per cent of patients remain well
without recurrence.

Those unfortunate persons who delay
medical consultation until the lesion is too

LeJeune — Carcinoma of Larynx

301

extensive for surgical intervention consti-
tute the last group. They have been classi-
fied as the extrinsic type of carcinoma of
the larynx which is seen all too frequently
for the first time in the office, consequent-
ly little or nothing can be done for them.
Radiation may prolong life, but we can
hardly hope for cure. This should not be
considered a condemnation of radiation
therapy for carcinoma of the larynx in gen-
eral. Although we are convinced that sur-
gical treatment offers the greatest number
of permanent cures, in properly selected
cases there has been sufficient evidence of
success in similar circumstances following
radiotherapy to warrant serious considera-
tion of this means of treatment.

Every case of persistent hoarseness
should be considered a potential case of
carcinoma of the larynx until proved other-
wise. If this policy were followed, an
earlier diagnosis would be made and if
proper measures were immediately insti-
stituted, a larger number of patients with
carcinoma of the larynx would be cured.
This policy can only be carried out by the
united cooperation of the entire medical
profession. The significance and serious-
ness of persistent hoarseness should be
broadcast repeatedly in an effort to make
the public realize that persistent hoarseness
is the danger signal of carcinoma of the
larynx.

DISCUSSION

Dr. L. W. Alexander (New Orleans) : This fine
paper by Dr. LeJeune is difficult to discuss due to
the fact that he has covered the subject so
thoroughly for the general practitioner, and this
presentation is especially directed to his attention.
It is most unfortunate that Dr. LeJeune was not
able to show the excellent colored movies that he
has made on many of his cases. I hope that at
a later date you will have the opportunity to see
the movies.

I would like to stress several important points
as brought out by Dr. LeJeune: (1) Cancer is sec-
ond only to heart disease as the cause of death in
this country; (2) five per cent of all malignancies
occur in the larynx; (3) the larger percentage of
cases occur between the fourth and seventh dec-
ades; (4) the early sign is hoarseness with no
pain; (5) no ear, nose, and throat examination is
complete without an examination of the larynx.

In a recent report by Dr. Max Cutter 413 cases
were reported in which only 88 cases were pre-

sented in its early stages. He is using in the early
cases a new type of x-ray treatment in which the
rays are concentrated upon a small area. The pa-
tients were treated twice a day from 11 to 18 days.
In fifty moderately early cases the lesion disap-
peared in 40 cases or 80 per cent. Twenty-three
out of 28 patients treated three years are at pres-
ent free of the disease and apparently cured.

Today man in his hurry is halted by one symp-
tom; if discovered early it may mean saving his
life. Hoarseness is a blessing in disguise to these
patients. The cancer cells are alive and growing. It
is an abnormal tissue producing abnormal symp-
toms of voice. The doctor must discover the lesion
early. A man freezing to death will die if not
aroused; therefore the public must be aroused to
cancer of the larynx.

I hope that this paper by Dr. LeJeune will stim-
ulate much discussion.

Dr. M. Manuel Garcia (New Orleans) : Being
a radiologist, I can say without bias that I con-
sider operation for laryngeal cancer one of the
real accomplishments of medicine. At the same
time it must be acknowledged that this type of
surgery suffers from many limitations and that it
provides only a partial solution to the problem of
laryngeal cancer.

As Dr. LeJeune has pointed out, many of the
patients unfortunately come to us with the disease
well advanced, when we are no longer able to of-
fer them the excellent possibilities for cure that
he has so ably presented. This is true principally
in extrinsic carcinoma, but it is also true in a
large measure in carcinoma of the cord itself, and
becomes more significant when we recall that the
so-called intrinsic type does not always have the
clear predominance indicated in the distribution
of cases shown by Dr. LeJeune. Our experience at
Charity Hospital has been somewhat different; ap-
proximately one-half of the cases we see are classi-
fied in the intrinsic group while the other half are
extrinsic. It follows that we are compelled to rely
on radiation for the control of a great many le-
sions.

Furthermore, I would venture to say that the
results of radiation are no longer to question, al-
though of course, they cannot compare with the
surgical results, since the two methods of treat-
ment deal with inherently different forms of the
disease, radiation being employed when operation
is no longer feasible, or when the patient refuses
operation. Dating back to 1928 when the pioneer
work of Coutard, of the Curie Institute in Paris
first furnished complete data on a large number
of cases treated by x-ray therapy, numerous studies
have become available clearly stating what can be
accomplished by this form of treatment. Radiation
yields from 13 to 28 per cent five year control ac-
cording to the reports published by Coutard, Mar-
tin of the Memorial Hospital, Chamberlain of Phil-
adelphia, Lenz of New York, and several others.

302

King — Roentgen Pelvimetry

At Charity Hospital there has been no opportun-
ity as yet to collect a sufficient number of cases
to state our results, but we know that patients are
alive and well today who at the time of admission
had perforation of the thyroid cartilage, or lim-
ited metastases in the neck, or some other type of
extensive local invasion. Moreover, we know that
the results of radiation are bound to improve as
our experience matures and our technical facilities
become perfected. The dosage requirements are
becoming better defined, the distribution of the
radiation in space and in time for the attainment
of optimum results are under constant investiga-
tion, and we know that accuracy in treatment de-
mands that the radiologist, like the laryngologist,
should be thoroughly acquainted by painstaking
frequent examinations with the precise extent of
the lesion and with the changes it manifests dur-
ing the course of treatment.

Dr. Val H. Fuchs (New Orleans) : Listening to
Dr. LeJeuna’s paper we all realize we are listen-
ing to the voice of a master in laryngeal surgery.
I have nothing to add except to mention one thing
he stressed, that is, do not wait so long to send
your patients in when they complain of hoarse-
ness. It is appalling how many cases we have seen
when patients go along for six or eight months
with hoarseness before the family doctor sends
them for examination. Send patients early and
we can do much more with them.

Dr. W. A. Wagner (New Orleans): I think Dr.
LeJeune’s presentation is a masterpiece. It not only
represents a report of his experience but a com-
plete resume of carcinoma of the larynx. I want
to congratulate him.

Dr. John T. Crebbin (New Orleans) : I wish to
emphasize the fact that patients who have had
their larynx removed may not be deprived the
pleasure of being able to talk. Formerly this was
done with the aid of a mechanical larynx, but in
recent years patients are encouraged to talk by
breath control, similar to belching.

Although, this method is difficult to acquire, it
is surprising how well many patients become ex-
perts and are able to converse over the telephone
and take part in public gatherings.

One cannot stress the importance of persistent
hoarseness, for this is a danger signal, which must
not be overlooked. Hoarseness of several weeks’
duration may mean a benign or malignant growth.
In either case, a laryngologist should be consulted
without delay.

Dr. F. E. LeJeune (in closing) : Dr. Garcia’s
discussion interested men very much as I believe
that the future treatment of cancer of the larynx
is going to be dependent largely upon the develop-
ment of radiation. Some of the results I have seen
have been most illuminating; others, of course,
most heartbreaking.

A number of years ago I recall seeing an old
Frenchman from Bayou LaFourche, born and

reared not far from where I grew up. He came to
me with a lesion involving one entire side of the
larynx. I had to speak French to him and I told
him that I was sorry but the only thing I had to
offer was extirpation of the larynx. He asked me
if I would have to take out the entire larynx and
if he would have to learn how to talk again, to
which I replied in the affirmative. He said that
the good Lord had put in his larynx to use and he
was going to use it as long as he was on this
earth. Since he refused to have an operation, I
suggested radiation, to which he finally agreed.
This patient represents one of the very few cases
in which the lesion will completely clear up fol-
lowing radiation and today, nearly six or seven
years after treatment, he remains perfectly well.
I would defy anyone to say that this patient ever
had a lesion in his larynx. He is as well as any
patient I have every seen. Other similar cases are
being reported throughout the country.

Because I have had some unpleasant experiences
following radiation, I have always been somewhat
skeptical about it and prefer surgery. However,
Dr. Garcia and his associates may be able to con-
vert me in the future. Certainly, radiation offers
much to the patient with cancer of the larynx, but
at the present time I feel that in early cases of
carcinoma of the larynx surgical intervention,
which guarantees cures in at least 75 per cent of
cases, is preferable to any other method which
promises less certain results. In all my surgical
cases I advocate postoperative radiation. Many
patients are given preoperative radiation for fix-
ation of cells in mitosis and postoperatively, addi-
tional radiation is given.

o

THE ROLE OF ROENTGEN
PELVIMETRY IN THE
MANAGEMENT OF PELVIC
CONTRADICTION*

E. L. KING, M. D.t
New Orleans

There is considerable difference of opin-
ion among obstetricians as to the value of
roentgenologic pelvimetry, hence this brief
presentation of the subject. Some feel that
such a study discloses nothing which can-
not be ascertained by a careful clinical
study of a given patient, while others con-
sider that an x-ray examination should be
made of every primipara and of every mul-

*Read before the annual meeting of the Louis-
iana State Medical Society, New Orleans, April
24-26, 1944.

tFrom the Department of Obstetrics, Tulane
University School of Medicine.

King — Roentgen Pelvimetry

303

tipara giving a history of previous difficult
labor. It appears that a “middle of the
road” attitude is the more logical one.

It is generally agreed that clinical pel-
vimetry does not always give us the final
answer as to the presence or absence of
disproportion. Let us remember that in
each obstetrical patient one of the most im-
portant questions is “Can this baby be de-
livered safely through this pelvis?” This
means that the baby must enter the inlet,
pass through the pelvic cavity, and emerge
through the outlet, all without injury due
to bony dystocia. It is obvious that a small
infant can traverse a small or a slightly
deformes pelvis, whereas as oversized child
might get into difficulty in a normal pelvis.
Hence we need to know the relationship be-
tween the two, as well as the details of the
pelvic measurements.

Again, we must remember that in clinical
pelvimetry we do not measure the various
pelvic diameters directly, but take certain
external and internal measurements, and
from them make estimates as to the diam-
eters. For example, we conclude that if
the external conjugate is 20 cm., the true
conjugate is normal, whereas if the former
is 17.5 or 18 cm., we assume that the latter
is shortened. However, if the sacrum is ab-
normally thick, the true conjugate may be
too short with a 20 cm. external conj ugate ;
on the other hand, with a thin sacrum, the
internal diameter may be normal even
though the external one be shortened.
Again, in a very stout patient, accurate
measurements are not possible.

When we consider the pelvic cavity we
find our difficulties increased, as there is
no way of measuring its diameters clinical-
ly, nor are there external measurements
from which we can make deductions as to
the internal ones. True, the diagonal con-
jugate, when it can be measured, gives us
the true conjugate when we subtract IV2
to 2 cm. This diagonal conjugate cannot al-
ways be measured, however; the examiner
must be equipped with fairly long fingers,
and the patient must be cooperative, with
relaxed soft parts. Again, the very impor-
tant diameter between the posterior infer-

ior ischial spines cannot be measured; we
can merely estimate whether or not it is
ample, and it is the transverse diameter of
the plane of least pelvic dimensions.

The pelvic outlet is easily accessible, and
its diameters, antero-posterior and trans-
verse, can be directly measured. The
tranverse, by the way, is 8 or 9 cm. on the
living patient. The figure of 10.5 to 11 cm.
applies to the dried bony pelvis. The sub-
pubic arch can be palpated and studied, the
configuration and mobility of the coccyx
can be noted, and the capacity of the an-
terior and posterior triangles can be esti-
mated.

What then can we do in the way of clin-
ical evaluation of the pelvis and of feto-
pelvic relationship ? We can take the usual
external measurements carefully and ac-
curately. We can, by a detailed digital
study of the pelvic cavity, obtain a fairly
satisfactory idea of the concavity of its
walls, of the shape and curvature of the
sacrum, and of the distance between the
spines and of the prominence of these
spines (whether normal or abnormal) . We
can attempt to measure the diagonal con-
jugate and thus to evaluate the true con-
jugate. We can study the outlet, and decide
whether it is normal or contracted. Then
we should try to estimate the size of the
fetus, remembering that the fundus at term
normally measures 33 to 35 cm. from the
symphysis. In case we are dealing with a
vertex presentation in a primipara, we
should find the head fairly well engaged in
the pelvis in the last eight or ten days of
pregnancy ; if it is not engaged by the time
labor starts, the possibility of disproportion
must be considered. In brief, if the pelvis,
externally and internally, appears normal;
if the fetal head in a primipara is engaged,
as above noted; if, in the case of a multi-
para, there is a history of normal delivery
of one or more babies weighing seven
pounds or over ; then we can feel reasonably
certain that vaginal delivery can occur
without undue difficulty and with little risk
to mother and child.

But suppose we find the pelvic measure-
ments smaller than normal; for example,

304

King — Roentgen Pelvimetry

interspinous 22 cm., intercristal 24 or 25
cm., external conjugate 17.5 or 18 cm. Or
suppose the pelvis cavity appears smaller
than normal on internal examination, with
ischial spines unduly prominent and some-
what closer together than is usual, or sup-
pose the outlet is contracted, with a small
transverse diameter and with a subpubic
angle rather than the normal ai'ch.

In the first instance, a trial of labor may
be resorted to, in an attempt to ascertain if
engagement of the head will occur in a
reasonable time. This trial of labor is of
value only in case of inlet contraction,
either in a generally contracted or a flat
pelvis. In the second type of case, with a
normal inlet but with a narrow plane of
least pelvic dimensions, we cannot resort
to the trial of labor. The head will engage,
but the problem is whether it will pass the
spines. This might be determined by vag-
inal examination after the head is well
down, the examiner trying to estimate the
size of the head as compared to the capac-
ity of this plane. If his estimate is correct,
and the head passes, well and good. How-
ever, if he is wrong, delivery will be dif-
ficult, with serious danger or death the
result for the child. And let us not forget
that with the head well down and with the
patient in labor for several hours, cesarean
section would be difficult and rather dan-
gerous. In this type of case, the x-ray is
particularly valuable. In the third category,
outlet contraction, the decision must be
made before, or as soon as, labor begins,
clinically if possible. If not, the x-ray will
again be of great value. We cannot per-
mit the head to reach the pelvic floor and
then find that it will not pass safely.

It would appear, then, that we do not
need roentgen pelvimetry in the multipara
with a history of normal vaginal delivery
of normally sized children, or in the primi-
Para with a clinically adequate pelvis, with
ischial spines that are not prominent and
are well spaced and with the head engaged
before labor starts. On the other hand,
we need further information in: (a) a mul-
tipara with a history of previous dys-
tocia; (b) a multipara with previous deliv-

ery of a small child who now presents her-
self with a much larger child, and (c) in a
primipara with an abnormal pelvis or with
an oversized child. At times the conditions
are such that clinical judgment will suffice
in aiding us to decide for or against cesarean
section, in other cases clinical judgment,
in my opinion, is inadequate.

My own practice is to proceed along
these lines. In the clinically normal pa-
tients I do not resort to x-ray unless it is
requested by the patients. In breech pres-
entation, I wish roentgen study of the size
and configuration of the pelvis, of the size
of the fetal head (which can be determined
by proper technic), and of the position of
the feet and legs of the fetus. In the mul-
tipara with unsatisfactory history, or in
the primipara with a pelvis suspected of
being abnormal, or an oversized child, I
also desire a careful and detailed x-ray
study. I do not feel that we should base our
decisions entirely on the roentgenologist’s
report, but it should be considered a very
important factor in our study of the case.

The particular technic to be employed is
the concern chiefly of the roentgenologist.
The Ball technic seems to be the most pop-
ular. In this method the volume capacity
of the pelvis at the various planes is deter-
mined, and also the volume of the fetal
head. When combined with the Johnson
method of calculating the various diam-
eters, much valuable information is ob-
tained. The Thom’s method is excellent,
but has not been used in this city. Of
course, the roentgenologist must be most
accurate and painstaking in this work. It
is generally agreed that a discrepancy of
not over 200 c. c. between the volume of the
head and the volume capacity of the pelvis
at the various planes can be overcome by
the molding of the head ; personally, I do
not like to exceed 180 to 190 c. c. I have in
the past few days delivered vaginally one
patient with a difference of 175 c. c. and
one with 180 c. c. I have found that the
greatest assistance from the x-ray has been
in the study of the plane of least pelvic
dimensions. I feel that the importance of

King — Roentgen Pelvimetry

305

this plane has not been stressed sufficient-

ly in our textbooks and in our

teaching.

The following cases are presented as ex-
emplifying the value of roentgen studies in
determining the method of delivery to be

employed :

CASE NO. 1

Pelvic Measurements :

Inlet:

Antero-posterior

10.7 cm.

Transverse

13.8 cm.

Left-oblique

12.0 cm.

Right-oblique

Outlet:

12.4 cm.

Antero-posterior (to sacrum)

10.9 cm.

Antero-posterior (to coccyx)

9.7 cm.

Transverse

10.6 cm.

Posterior-sagittal
Plane of Least Pelvic Diameters :

6.0 cm.

Antero-posterior

10.9 cm.

Transverse

10.3 cm.

(Volumetric capacity 570 c.

c.)

Fetal Skull:

Fronto-occipital

12.2 cm.

Circumference

35.1 cm.

Volume

740 c. c.

Note: — The volume of the head is 170 c. c.
greater than the V.C. of the plane of least
pelvic diameters. This was compensated for
by moulding and normal delivery occurred.
Another patient with a discrepancy of 180 c. c.
was delivered normally.

CASE NO. 2

Inlet:

Antero-posterior

12.2 cm.

Transverse

13.3 cm.

Right oblique

13.0 cm.

Left oblique

13.1 cm.

Outlet:

Antero-posterior (to sacrum)

11.4 cm.

Antero-posterior (to coccyx)

10.0 cm.

Transverse

10.3 cm.

Posterior sagittal

7.0 cm.

Plane of Least Pelvic Diameters .-

Antero-posterior

11.4 cm.

Transverse

9.5 cm.

(Volumetric capacity 450

c. c.)

Fetal Skull:

Fronto-occipital

12.0 cm.

Circumference

34.9 cm.

Volume

720 c. c.

Note: — The volume of the head

is 270 c. c.

greater than the V.C. of the plane of least
pelvic diameters. This patient was sectioned.

CASE NO. 3
Inlet:

Antero-posterior 11.4 cm.

Transverse 13.9 cm.

Right oblique

12.4 cm.

Left oblique

12.5 cm.

Outlet:

Antero-posterior (to sacrum)

12.7 cm.

Antero-posterior (to coccyx)

11.0 cm.

Transverse

10.8 cm.

Posterior sagittal

7.2 cm.

Plane of Least Pelvic Diameters .-

Antero-posterior

12.7 cm.

Transverse

9.7 cm.

(Volumetric capacity 480 c. c.)

Fetal Skull:

Fronto-occipital

11.6 cm.

Circumference

35.4 cm.

Volume

750 c. c.

Note: — This patient also had a discrepancy of

270 c. c. and was sectioned.

:ASE no. 4

Inlet:

Antero-posterior

12.0 cm.

Transverse

11.7 cm.

Right oblique

12.6 cm.

Left oblique

12.2 cm.

Outlet:

Antero-posterior (to sacrum)

11.5 cm.

Antero-posterior (to coccyx)

10.1 cm.

Transverse

10.7 cm.

Posterior sagittal

6.9 cm.

Plane of Least Pelvic Diameters:

Antero-posterior

11.5 cm.

Transverse

9.1 cm.

(Volumetric capacity 395

c. c.

Fetal Skull:

Fronto-occipital •

11.6 cm.

Circumference

32.6 cm.

Volume

585 c. c.

Note: — In this patient the discrepancy was 190

c. c. This was so close to the upper limit of

200 c. c. that it was felt best to

deliver by

section. Note also that the inlet is

transverse-

ly contracted with the A-P a little longer than

normal.

>ASE NO 5

Inlet:

Antero-posterior

10.5 cm.

Transverse

13.4 cm.

Right oblique

12.3 cm.

Left oblique

12.5 cm.

Outlet:

Antero-posterior (to sacrum)

10.5 cm.

Antero-posterior (to coccyx)

9.1 cm.

Transverse

10.4 cm.

Posterior sagittal

5.5 cm.

Plane of Least Pelvic Diameters

Antero-posterior

10.5 cm.

Transverse

9.3 cm.

(Volumetric capacity 425 c.

. c.)

Fetal Skull:

Fronto-occipital

12.2 cm.

Circumference

34.0 cm.

Volume

660 c. c.

306

King — Roentgen Pelvimetry

Note: — In this case there was a discrepancy of
235 c. c. so section was performed.

cask no. i;

Inlet

Antero-posterior 11.9

Transverse 12.9

Right oblique 12.9

Left oblique 12.8

Outlet.

Antero-posterior (to sacrum) 11.1

Antero-posterior (to coccyx) 8.5

Transverse 10.7

Posterior sagittal (to sacrum) 6.8

Posterior sagittal (to coccyx) 3.5

Plane of Least Pelvic Diameters

Antero-posterior (to tip of coccyx) 8.5

(Volumetric capacity 320 c. c.)
Transverse 9.0

(Volumetric capacity 385 c. c.)

cm.

cm.

cm.

cm.

cm.

cm.

cm.

cm.

cm.

cm.

cm.

Note: — This was a case of generally contracted
pelvis as is seen from the above measure-
ments. The first baby had been lost at de-
livery. These measurements were taken at
five months and an elective section was per-
formed at term.

Inlet

Antero-posterior
Transverse
Right oblique
Left oblique

10.5 cm.

13.6 cm.
11.9 cm.
11.9 cm.

Outlet

Antero-posterior (to sacrum) 9.0 cm.

(Volumetric capacity 385 c. c.)
Antero-posterior (to coccyx) 7.0 cm.

Transverse 12.3 cm.

Posterior sagittal 6.2 cm.

Plane of Least Pelvic Diameters

Antero-posterior 9.0 cm.

(Volumetric capacity 385
T ransverse
Fetal Skull:

Circumference

Volume

c. c.)

12.0 cm.

30.5 cm.
475 c. c.

Note: — This patient had a generally contracted
pelvis involving all planes. The discrepancy
was only 90 c. c., but in view of the fact that,
as above stated, all planes were contracted it
was felt best to deliver her by section.

CONCLUSION

I 1‘eel that roentgen pelvimetry has a
piece of distinct value in the study of the
types of cases outlined above. This is the
view taken by most writers on obstetrics.
As stated above, we do not as a rule base
the decision entirely on the x-ray, but use
the findings in conjunction with our clinical
studies. Thus employed, the roentgen study

is a very valuable aid in the cases under
consideration.

DISCUSSION

Dr. J. N. Ane (New Orleans) : I wish to thank
Dr. King for the privilege of discussing his paper.
His indications for roentgen pelvimetry should
cover all types of cases requiring this method of
examination. It is true that the value of this
method must be determined in each individual
case by the obstetrician.

Dr. King has stressed the necessity of careful
clinical examination in the selection of cases for
roentgen pelvimetry. This is important because
roentgen pelvimetry can be done more accurately
and efficiently on dry films before the onset of
labor than on wet films after the patient has been
in labor for a number of hours with no evidence
of progress.

The three most popular methods of roentgen
pelvimetry are: (1) The position or frame technics
of Thomas and Jarcho with the many modifications
including the opaque rule notched at each centi-
meter of length; (2) the stereoscopic methods of
Johnson and of Moloy; (3) the volumetric meth-
ods of Ball and of Snow.

The Johnson method is considered the most ac-
curate form of roentgen pelvimetry. The error
should not exceed 2 mm. Another important ad-
vantage of his procedure is the opportunity of
studying the bony pelvis and the fetal skull stereo-
scopically as advocated by Moloy and Swenson.
While the diameters of the fetal skull can be deter-
mined in about 94 per cent of cases, diameters are
not completely satisfactory because of the varia-
tion in the shapes of the fetal skull and because
comparisons of fetal skull diameters and pelvic
diameters are unsatisfactory. The Ball method of-
fers the opportunity of comparing volume of fetal
skull and volumetric capacity of pelvic diameters.
Therefore, we have found that the combination of
the Johnson and Ball methods offers the most sat-
isfactory procedure for obtaining the greatest
amount of information.

In an analysis of 1,406 cases measured, normal
cr greater than normal diameters were found in
881, or 63 per cent; contractions in one or more
diameters of from 5 to 10 mm. were noted in 329,
or 23 per cent, and contraction of 10 mm. or more
in 14 per cent.

Dr. Menville and I were able to correlate roent-
gen pelvimetry with type of delivery in 362 cases.
Of this group 205 were found to have normal
diameters and 203 or 99 per cent delivered nor-
mally. Sixty-one cases had a contraction in one
or more diameters of 10 mm. or more, and of
these 52, or 85.2 per cent, required operative de-
liveries.

I agree with Dr. King that the importance of
the mid-plane diameters has not been stressed suf-
ficiently. In 44 cases in which the interspinous or
bi-ischial diameter was contracted more than 10
mm., only 3 or 7 per cent delivered normally.

Sodeman AND Engelhardt — Causes of Syncope

307

The incidence of serious contraction in the inlet
alone was an infrequent finding. The majority of
cases which failed to engage because of bony dis-
proportion also showed contraction in the mid-
plane and outlet diameters as well.

Dr. Walter Levy (New Orleans) : I think that
x-ray pelvimetry is a valuable aid to the obstetri-
cian, It does not tell everything but it is an ad-
junct to diagnosis. Since the advent of x-ray
pelvimetry, we have become much more conscious
of pelvic architecture than before. We are using
the classification of Caldwell and Moloy on the
findings. By studying the pelvis from that stand-
point clinically, and by x-ray, I think we are more
apt to predict the type of labor we are going to
have. Furthermore the x-ray is not the final an-
swer to two things — how much that baby’s head is
going to mold and how much effort the woman is
going to put out to deliver the baby. These are
unknown factors which can not be anticipated
clinically or by x-ray. Some cases have been seen
at Touro which we thought with effort on the part
of the mother would come through, but did not.
Others on the x-ray plate seemed very likely
to come through and did not.

I do not think Dr. King mentioned as to when
these pictures should be taken. They should not be
taken at the eighth month. They should be taken
as near to the time of the anticipated labor as pos-
sible. I heartily agree with Dr. Ane as to mid-
plane contraction being a dangerous one, partic-
ularly in occiput posteriors. They can not resolve
as easily with mid-plane contraction. I think in
the android type (male type) we get a higher per-
centage of posterior positions. In a breech where
we really would like to know something as to head
size we do not get as much knowledge as we should
like for the obvious reason that the radiologists
have not been able to give estimated number of
millimeters of head as compared to pelvis. To re-
peat, if the x-ray has done nothing more, it has
made us conscious of the architecture of the pelvis.

Internal measurements are the most important,
and it is equally as important to take measure-
ments of the outlet.

Dr. J. W. Reddoch (New Orleans) : There is

one point that I would like to bring out. Even
though the pelvic measurements are normal, soft
tissue dystocia has to be watched for. In this re-
spect x-ray pelvimetry may be misleading, and
what was thought to be an easy delivery really be-
comes very difficult, because of dense, unyielding
soft tissue.

I believe Dr. King is correct in his estimate of
mid-plane difficulties ; it is at this pelvic level that
the major troubles may arise.

I believe that Dr. Levy did not hear Dr. King
when he stated that the x-ray studies are made
about ten days before the expected date.

Dr. E. L. King, (in closing) : Dr. Levy stressed
the molding of the fetal head and character of
pains the patient is going to have; we can not

determine that ahead of time by any method at
our command. Some writer several years ago
published an article claiming that giving excessive
amounts of calcium before delivery increased dif-
ficulty of delivery because of increased calcium of
the head. I do not think that is correct. I give
adequate amount by milk or in other ways and
have not had difficulty from that point ; but we
can not say, particularly in a postmature baby,
how much that head will mold or how the patient
will work or co-operate. The time to take the pic-
ture is a week or ten days before we expect deliv-
ery. That is difficult to determine; sometimes we
get pictures too soon and sometimes get them the
day before labor and get the report after the baby
is born.

Another point I would like to make is if the de-
livery is a good deal further off than anticipated
— three or four weeks, which is not at all uncom-
mon— and there is some question about the orig-
inal film, we should have another made. If we cal-
culate the baby is due on a certain day and be-
cause of some perversity on the part of nature it
is a week later, and the first set of pictures did
not give much leeway, although all right at that
time, we get another set. I did that with a patient
who went five and a half weeks after expected de-
livery. We tried to induce labor but did' not make
the grade. The first set showed no disproportion.
The next set showed 250 c. c.

The volume of the head in breech can be deter-
mined fairly well if you use special method but
not on ordinary pictures; there is a special technic
and method to get head measurements in breech
delivery. As brought out the question of the shape
of the sacrum on lateral views is extremely impor-
tant. Of course we may get soft tissue dystocia
and we can only estimate this clinically.

0

THE CAUSES OF SYNCOPE WITH
SPECIAL REFERENCE TO
THE HEART*

W. A. SODEMAN, M. D.t

AND

H. T. ENGLEHARDT, M. D.t
New Orleans

Transient, sudden loss of consciousness
of short duration is termed syncope. Such
states, if prolonged, and particularly if the

*Read before the sixty-fifth annual meeting of
the Louisiana State Medical Society, New Orleans,
April 24-26, 1944.

(From the Department of Preventive Medicine,
School of Medicine, Tulane University of Louis-
iana.

JFrom the Department of Medicine, School of
Medicine, Tulane University of Louis4ana.

308

Sodeman and Engelhardt — Causes of Syncope

unset is gradual, are termed coma. Both
conditions differ from sleep in that non-
injurious stimuli do not affect the state of
unconsciousness. The events leading to
syncope may stop short of a stimulus suf-
ficient to cause unconsciousness so that
light-headedness, a sinking sensation,
numbness of the hands and feet, epigastric
or precordial uneasiness, weakness, yawn-
ing, and nausea may represent the episode
without actual loss of consciousness.

Despite the fact that a number of mech-
anisms underlie the development of syn-
cope, the outward appearances of the
patient are usually the same, save for varia-
tions in the picture dependent upon the
speed of development and the intensity
of the attack. The patient, usually in the
standing or sitting position, collapses and
the body lies limp and motionless. Facial
pallor is marked; pupils are dilated and
respiration becomes slow and either shallow
or deep. Muscle twitching and, at times,
even convulsions are seen. The attack, of
short duration, usually quickly terminates
when the horizontal position is assumed,
and the episode is often over before com-
petent medical observation of the pulse and
blood pressure can be made.

Such attacks, since they frequently occur
in healthy people without demonstrable se-
rious disease to account for them, are
usually given little serious thought by the
physician despite the drama and the furor
amongst the laity on their occurrence. This
attitude, coupled with the fact that the phy-
sician is likely to see the patient only after
the attack has terminated, has led to neg-
lect of the patient showing these symptoms,
especially in their milder forms, when a
mechanism may be discovered which may
be relieved. Of importance is the fact that,
if such patients are seen in an attack, ob-
servations upon the cardiovascular system
are very helpful in the determination of the
type of reaction present. This is essential
in therapy, for two episodes which are de-
scribed by the patient or onlookers as iden-
tical not only may require different forms
of treatment but the therapy for one may
be disastrous if applied to the other.

Observation of a number of patients
with syncope related to heart disease, in-
cluding several patients with syncope on
exertion, has led us to a survey of syncope
in relationship to heart disease. The most
satisfactory classification of syncope which
we have noted is that of Soma Weiss1. His
grouping consists of a simple listing of the
various types of syncope, the entities being
separated on the basis of mechanism and
causative factors. This work has been a
definite advance in the consideration of
syncopal states. We have found it profit-
able, in the clinical approach, to subdivide
this list and regroup syncopal states, not on
the basis of the underlying mechanism
leading to a disturbed circulatory balance,
but upon the basis of the resultant altered
hemodynamics. These changes, which can
be determined rapidly by examination of
the patient, along with certain historical
facts, make up a set of data which quickly
rules out certain possibilities in diagnosis
and rules in others, narrowing and simpli-
fying the problem of differential diagnosis
as well as indicating possible approaches
and dangers in treatment.

We propose to group syncopes into three
categories : The first includes those patients
in whom the mechanism underlying dis-
turbed blood flow to the brain effects a
pooling or deviation of blood which inter-
feres with return flow to the heart. In this
group, blood does not return to the heart
in sufficient amounts to maintain adequate
cerebral circulation. Since the disturbance
in circulation occurs before blood gets to
the heart, we call this type precardiac.

The second category consists of those in
whom return of blood to the heart is ade-
quate, but the heart fails to function
adequately as a pump, as in extreme tachy-
cardia, or asystole. This we call cardiac
syncope, although it does not necessarily
imply organic heart disease. Nathanson2
has defined cardiac syncope as sudden loss
of consciousness due to cerebral anemia of
cardiac origin, and sudden cardiac death as
fatal cardiac syncope.

The third group includes those in whom
both of the above factors are normal, but

Sodeman and Engelhardt — Causes of Stjncope

309

in whom there is an interference in blood
flow to the brain somewhere between the
heart and the brain itself. This is a post-
cardiac type.

In table 1 are listed the syndromes and
conditions which produce syncope. These
have been grouped into the three types,
precardiac, cardiac, and postcardiac. It can

TABLE 1

TYPES OF SYNCOPE
Precardiac

Common fainting attacks
Postural hypotension

Carotid sinus syndrome — peripheral type
Pleural and peritoneal “shock”

Shock pictures, as with coronary thrombosis
“Central vasomotor” syncope (including hyper-
ventilation syndrome)

Pulmonary vascular disturbances
Cardiac

Vagal stimulation pictures

Carotid sinus syndrome — cardiac type
Oculovagal syncope
Vagovagal syncope
Pleural shock — vagal picture
Stokes-Adams syndrome — organic cardiac
Asystole

Slow ventricular rate
Shifting ventricular pacemaker
Tachycardias

Paroxysmal tachycardia
Auricular flutter and fibrillation
Ventricular fibrillation
Congestive and anginal heart failure
Postcardiac

Carotid sinus syndrome — cerebral type

Hypertensive encephalopathy

Cerebral engorgement

Dissecting aneurysm

Hypoglycemic reactions

Angina pectoris

Aortic stenosis

(

be seen that the precardiac variety includes
that group in which there is a sudden drop
in pulse pressure associated, just before the
syncope, with some rise in heart rate which
usually falls due to vagal responses almost
simultaneously with the onset of fainting.
The fall is often to the range of 40./minute
and not in the range seen in the cardiac
type next to be described. Such findings in
a patient lead immediately to a considera-
tion of the mechanisms listed under pre-
cardiac in table 1 and those in the other
two groups may be disregarded. The prob-

lem of differential diagnosis is greatly nar-
rowed and attention may be focused on the
few types of syncope producing this pic-
ture. Therapeutic procedures in instant
need become immediately apparent ; those
which can be disregarded are known at
once, for the prompt treatment of patients
with precardiac syncope depends not pri-
marily upon the mechanism producing the
hemodynamic changes causing the syncope
but on relief of the hemodynamic changes
themselves, a change common to all types
in this group.

This reaction is the type seen in common
fainting attacks, a condition to which Lewis
applied the term vasovagal syncope. There
has been objection to the use of this term
because the vagal effect is not essential to
the syncope, which may occur when the
vagus is paralyzed with atropine. Tho
causes of common fainting attacks, the
most common type of syncope, we shall not
dwell upon. Sight of blood, overheating,
venepuncture, emotional upsets and similar
reactions, anemia, malnutrition, patent
ductus arteriosus, aortic regurgitation, con-
genitally narrow aorta, instrumentation of
the bladder, are only a few of the many
causes, which range from unimportant re-
actions to serious organic disease. Postural
hypotension falls into the precardiac group
with changes in pulse pressure and pulse
quite similar to those in common fainting
attacks. The peripheral type of cartoid
sinus syndrome, that resulting in dilatation
of peripheral vessels with drop in blood
pressure when the carotid sinus is stimu-
lated, is also in the same group, as are cer-
tain types of pleural and peritoneal
“shock.” All the reactions that occur when
the pleural space is invaded by a needle are
not explained as precardiac syncope, but
precardiac syncope is one of the reactions
which does result from such procedures.
So-called “peritoneal shock,” in which there
is sudden loss of pressure in the peritoneal
cavity, falls into the same category.

What is commonly called shock, either re-
sulting from surgical or medical conditions,
usually appears in the differential diagno-
sis of syncope. The changes which develop

310

Sodeman and Engelhardt — Causes of Syncope

in the circulation — pallor, venous collapse,
falling blood pressure — are quite compar-
able in common fainting attacks and in the
picture of shock seen from coronary throm-
bosis, trauma and other etiologic agents.
Since syncope is a transient loss of con-
sciousness which comes on suddenly and
lasts for a short period of time, it may be
associated with shock, and, therefore, can-
not be differentiated from shock when
defined in this way. Shock can be differ-
entiated from common fainting attacks for
here we imply not only transient uncon-
sciousness but a vascular mechanism. In
essence, common fainting attacks and
shock, therefore, differs from common
fainting attacks, changes in the circulation
are temporary and reversible, whereas in
the usual shock picture, the circulatory
changes are prolonged. The picture of
shock, therefore, differs from common
fainting attacks primarily in the transient
nature and reversibility of the latter and
the persistence of the former. The differ-
entiation goes back to the cause, the cause
of common fainting attacks being transient,
being corrected by a change of position,
those of shock not being transient and not
being corrected by a change in position.

The condition described by Weiss as cen-
tral vasomotor syncope, and exemplified by
syncopal reactions to local anaesthetics
and brain tumors, also falls into this group.
Here also go pulmonary vascular changes
that result, for example, from the Valsalva
experiment, following which venous re-
turn is temporarily stopped, as well as pul-
monary vascular disturbances resulting
from compression of the thorax after
which sudden release of pressure produces
some pooling of blood in the chest.

All the pictures of precardiac syncope,
then, are characterized by some disturb-
ance in return of blood to the heart result-
ing in inadequate output and disturbed
cerebral circulation.

Cardiac syncope, the second grouping in
table I, may be broken down into at least
three categories. All are characterized by
extreme changes in heart rate with accom-
panying blood pressure changes. This find-

ing differentiates the accompanying syn-
cope from the other two groups, and, to
repeat the I’emarks made in the discussion
of the precardiac group, narrows the prob-
lem of differential diagnosis and immedi-
ately points out the direction which therapy
must take.

The first of the three categories in this
group is that of vagal stimulation resulting
in asystole or a markedly slowed ventricu-
lar rate. Such vagal stimulation, if suffi-
cient to produce an inadequate minute
output of blood despite the fact that the
output produced by each beat is greater
than normal, will result in a picture of
asystole with the blood pressure approach-
ing zero, or very slow heart rate in which
the change in blood pressure is less
marked. Such pictures of vagal stimulation
may be the result of hyperactive carotid
sinus or of other reflexes, such as the ocu-
lovagal or vagovagal reflex, characterized
by afferent stimuli arising from a vagal
source being sent as efferent stimuli again
down the vagus. Such pictures have been
described in individuals with syncope on
swallowing when a diverticulum of the
esophagus has instigated the reflex. Pleu-
ral shock falls into this group if the reflex
produced by the pleural stimulation is
manifested in vagal stimulation.

Obviously these pictures may occur in the
absence of organic heart disease. It is not
usual for more than one of these reflexes
to be hyperactive at a time. For example,
the oculovagal reflex may be hyperactive
when the carotid sinus reflex is normal.

Secondly, cardiac syncope may be pro-
duced when organic disease of the heart
interferes with conduction from the auricle
to the ventricle. This is the so-called
Stokes-Adams syndrome of organic heart
disease. The change from normal conduc-
tion or partial heart block to complete heart
block may occur with a latent period be-
fore the ventricle takes up its own rhythm.
If this period is sufficiently long, syncope
may develop along with convulsions and
the other symptoms characteristic of
Stokes-Adams attacks. The same picture
may develop if the ventricle does not stop

311

Sodeman and Engelhardt — Causes of Syncope

beating but the ventricular pacemaker, al-
though becoming active quickly, is suffi-
ciently slow, let us say eight beats per min-
ute, to produce long intervals between each
beat. Stokes-Adams syndrome may also de-
velop in complete heart block, as is not fre-
quently appreciated by many physicians,
when the ventricular pacemaker shifts to
another center which discharges at a very
slow rate or with transient seizures of ven-
tricular fibrillation.

In the third category under the cardiac
grouping, the heart rate is extremely rapid,
as in paroxysmal tachycardia or 1:1 au-
ricular flutter; the efficiency of the heart
as a pump is markedly reduced, and the
cardiac output is so diminished that cere-
bral circulation is impaired. When this pic-
ture becomes sufficiently advanced syncope
develops.

Cardiac syncope, therefore, may result
from extremely slow hearts or extremely
rapid hearts, both producing an inadequate
output of blood. Both again may occur in
the absence of organic heart disease or in
the presence of organic heart disease.
Under either circumstance the picture is
a dramatic one which requires effective
treatment.

Under the term cardiac syncope we must
also discuss certain episodes of fainting as-
sociated with aortic stenosis and congestive
and anginal heart failure. Proper classifi-
cation of this group is not possible, but it
is mentioned here because some believe that
with congestive or anginal heart failure,
particularly with exertion, the heart may
not be able to increase its output suffi-
ciently to meet the demands in the peri-
phery. Here, despite the fact that blood
pressure and heart rate would not be re-
markably out of the range of normal, syn-
cope might develop because of the inade-
quate response of the heart to exercise.
That this mechanism is active in such pa-
tients and does enter into the development
of syncope is not definitely established.
For the present, however, since heart rate
and pulse pressure are not remarkably al-
tered and cardiac output is probably not

reduced, we are placing these types in the
postcardiac grouping.

The postcardiac group is characterized
by syncope in the absence of lowered pulse
pressure and extreme change in heart rate ;
and in their absence, the entities already
discussed, except syncope on exertion with
angina pectoris and aortic stenosis, need
not enter in the differential diagnosis.
Postcardiac syncope is most clearly exem-
plified by the third type of carotid sinus
syndrome — the cerebral type. Since this
can be produced experimentally in patients
by digital pressure on the carotid sinus, it
has been studied quite thoroughly, particu-
larly by Weiss and his group. It is well
known that carotid sinus stimulation may
result in syncope despite the fact that the
blood pressure is not lowered and despite
the fact that the heart rate is not dis-
turbed. In patients in whom mixed types
of carotid sinus reflex occur, thorough
atropinization to eliminate vagal effects
does not stop the occurrence of syncope. In
attacks, these patients become extremely
pale and faint apparently from vascular ef-
fects in the brain. Weiss was able to show
that there was no evidence of sufficient
disturbance in the total cerebral circulation
to account for the syncope. He has sug-
gested that there may be localized disturb-
ances in circulation affecting a portion of
the midbrain which controls consciousness.
Such attacks .are frequently accompanied
by convulsions which leads to their being-
considered, particularly when they occur
spontaneously, as epileptic seizures. This
part of the problem will not be discussed
here except to state that there is adequate
evidence to indicate that such episodes are
not of the nature of epilepsy.

Syncope may also develop under other
circumstances when the precardiac and
cardiac mechanisms are not active, with
disturbances in the circulation to the brain
in the absence of diminished output by the
heart. Syncope of hypertensive crises falls
into this category, as does that accompany-
ing cerebral engorgement. Syncope asso-
ciated with dissecting aneurysm likewise
may fall into this group, but it is not clear

312

Sodeman and Engelhardt — Causes of Syncope

in )me of these patients that stimulation
of t'.e aortic nerves and vagal effects may
not be responsible for the syncope. The
transient, sudden loss of consciousness
which occurs in hypoglycemic reactions is
considered in the same category and pos-
sibly is explained by biochemical changes
in the brain rather than upon circulatory
disturbances. These transient losses of con-
sciousness do fit the definition of syncope
and are certainly postcardiac in type.

Angina pectoris and aortic stenosis are
two conditions in which syncope has been
noted and in which, in certain patients,
changes in the blood pressure and pulse
have not occurred. This would indicate,
then, a disturbance in cerebral circulation
not accounted for by reduction in cardiac
output. It is possible, since these episodes
of syncope occur on exertion, that the ex-
planation of syncope in some of these pa-
tients lies in inadequate increase in cardiac
output, as stated under the discussion of
cardiac syncope, but there is little evidence
to make this differentiation and in the ab-
sence of remarkable changes in blood pres-
sure and heart rate we prefer to put them
in this group. In both angina pectoris and
aortic stenosis in some instances it is
known that the other types of syncope, both
precardiac and cardiac, are active in the
production of fainting attacks. In those in
whom this is not true, the postcardiac
mechanism is most likely active.

One can see from the numerous types of
fainting that a classification of the patient,
if possible, into one of the three groups
advocated simplifies the problem as far as
clinical approach is concerned. Such classi-

fication does not indicate the mechanism
responsible for the disturbance in circula-
tion but does localize the changes in the
cardiovascular system. Under those cir-
cumstances then, the number of conditions
to be considered in differential diagnosis is
greatly reduced. The classification is advo-
cated primarily because of the help it gives
in the bedside approach to the diagnosis,
and, as we shall see, in therapy. The dif-
ferential points on precardiac, cardiac, and
postcardiac syncope are summarized in
table 2.

Heart disease may produce syncope
which falls into any of these three groups.
It is, therefore, important that the particu-
lar types of heart disease which are causes
of syncope in each group be considered as
the occasion demands. In the precardiac
type, the relationship of such conditions as
coronary thrombosis to syncope with the
sudden development of shock pictures is
evident. Cookson3 found, among 200 pa-
tients with acute cardiac infarction, synco-
pal or epileptiform attacks in 15. Syncope
occurred in 10 at the onset in the presence
of apparently severe peripheral circulatory
failure. In 5 of the group the patients were
over 70 years of age, indicating the possi-
bility that cerebral arteriosclerotic disease
may be of some importance in the develop-
ment of syncope.

Even common fainting attacks may be
of extreme importance in the elderly ar-
teriosclerotic cardiac patient, especially
when convalescing from prolonged bed
rest. Sudden death in such patients who
unexpectedly collapse in getting out of bed
after prolonged rest is often unexplained.

TABLE 2

TYPES OF SYNCOPE

Differential Points

PKEJCARDIAC CARDIAC POSTCARDIAC

Pulse pressure Falls Falls Depends upon cause,

no fall

Heart rate - Falls, then rises Very rapid or very slow No extreme change

Color Pallor Pallor then cyanosis Pallor, no change

Convulsions Rare Common Variable

Respiration Slow & shallow Slow & shallow Slow & shallow

or hyperpnea or hyperpnea or hyperpnea

Sodeman and Engelhardt — Causes of Syncope

313

For example, in a necropsy series of coro-
nary artery disease, Nathanson2 was unable
in most instances to explain sudden death
on an anatomic basis. Myocardial infarc-
tion, cerebrovascular accidents and em-
bolic phenomena, so often expected, were
not generally found. The heart was usually
normal in size or only moderately enlarged
and the structure of the myocardium, ex-
cept in a small group, was compatible with
life and an efficient circulation. Such evi-
dence indicates that the mechanism of sud-
den death in coronary disease is probably
usually physiologic. The two well recog-
nized mechanisms leading to syncope and
death are cardiac standstill and ventricular
fibrilliation. Weiss1 suggests that at times
common fainting attacks may be respon-
sible for the fatal outcome. Cardiac pa-
tients, during convalescence, are likely to
be propped up in a wheelchair, a position
in which syncopal attacks based upon an
unstable vasomotor tonus and peripheral
pooling are likely to occur. When such at-
tacks do occur, the most important thera-
peutic procedure is the assumption of the
horizontal position. The development of
syncope, the loss of reflexes, permits the
patient, when standing, to fall to the floor
and assume this position. The cardiac pa-
tient who is propped up in a chair may, if
he faints, not be able to assume the hori-
zontal position. The persistence of the up-
right position would permit a prolonged
period in which the pulse pressure is mark-
edly diminished and is likely responsible for
sudden death at times in such patients. It,
therefore, is important in elderly patients
with arteriosclerotic heart disease, particu-
larly those who have a prolonged rest in
bed, that they be watched during con-
valescence and not be placed under circum-
stances in which syncope may develop when
they cannot assume the horizontal position.

Another relationship of the precardiac
type of syncope to heart disease which is
of considerable importance is the hyper-
activation of the carotid sinus by digitaliza-
tion, particularly in older and sclerotic indi-
viduals in whom this reflex is likely to be
hyperactive anyway. Digitalization is a

frequent cause of hyperactive carotid sinus
syndrome whether of the peripheral, car-
diac, or cerebral type. Weiss again points
out that the procedure of digitalizing older
individuals without heart failure as a pro-
phylactic preoperative measure sometimes
may lead to clinical pictures resulting from
the hyperactive carotid sinus reflex, espe-
cially if the anesthetist creates pressure on
the neck during anesthesia in adjusting the
head or in taking the pulse. There is no
adequate reason to digitalize such patients
prophylactically because of the infre-
quency of the development of congestive
heart failure in its absence preoperatively
and because of the adequate means at the
present time for rapid digitalization.

The cardiac type of syncope, resulting
either from the vagal or non-reflex types of
Stokes-Adams syndrome or from extreme
tachycardia, needs little comment in rela-
tionship to heart disease. The points of dif-
ferentiation of the vagal picture from the
organic type of Stokes-Adams syndrome
are evident. At times syncope which is de-
scribed as resulting from auricular fibrilla-
tion may not necessarily arise upon this
mechanism for, as Comeau4 has pointed
out, the ventricular standstill which results
during the transition from the normal
rhythm to fibrillation may be responsible
for syncope that comes on with attacks of
fibrillation rather than the tachycardia of
the fibrillation itself.

The postcardiac types of syncope, par-
ticularly in relationship to heart disease,
are most interesting because of the doubt
which arises in the explanation of the pro-
duction of symptoms. Hyperactivity of the
carotid sinus in patients with arteriosclero-
tic disease has already been mentioned. In
hypertensive crises and in dissecting aneu-
rysm, relationships to heart disease are
fairly clear-cut and need little comment
here. However, some of the others deserve
further comment.

In angina pectoris and aortic stenosis the
relationship of the syncope to exertion is
quite striking and is of great help in diag-
nosis. At times in other forms of heart
disease a relationship to exertion is seen.

314

Sodeman and Engelhardt — Causes of Syncope

Congenital heart disease, particularly with
hypoplasia of the aorta, aortic regurgita-
tion, mitral stenosis, congestive heart fail-
ure especially with pulmonary edema and
cardiac asthma, are occasionally accompa-
nied by syncope on exertion, but not as
strikingly as is aortic stenosis and, at
times, angina pectoris. It will be noted that
these are likely to develop without regard
to exercise. As a matter of fact, exercise
may benefit venous return in the precardiac
type and thereby help to prevent fainting.
In syncope on exertion one should look for
angina pectoris or aortic stenosis in the
background. Angina pectoris sometimes is
associated with aortic stenosis, and angina
pectoris, aortic stenosis and syncope may
occur in the same patient.

The association of exertion and syncope
has received little attention in the litera-
ture. White5 has found that syncope is un-
common in angina pectoris and occurs only
occasionally. Greatest interest has been in
the French literature. Gallavardin has
noted syncope with auriculoventricular dis-
sociation0, with a normal cardiac mech-
anism and hypotension7, and with aortic
stenosis8. The association of syncope and
effort has been described by others. Gra-
vier’s patient1' had a normal mechanism
during attacks, and we have seen two pa-
tients of this sort.

The mechanisms whereby anginal pain
develops in aortic stenosis are not clear
and have never been adequately worked
out. Autopsy studies10 indicate in some of
these patients that the aortic lesions are
not in close association with the coronary
orifices. Several explanations have been
given which involve the failure of the
cusps to cover the coronary orifice when
open. This could produce a suction effect
in the coronary arteries comparable to the
mechanism utilized in the cleaning of
pipettes and be responsible for the anginal
syndrome. A discrepancy between coro-
nary circulation and cardiac work has
been put forward.

The mechanics of syncope are not clear
in those instances in which the blood pres-
sure and pulse are not markedly changed.

Marvin and Sullivan11 felt that activity of
the carotid sinus might be responsible and
French reports also favor some type of
nervous mechanism. Carotid sinus activity
has not been proved in a number of cases
where tested10 and furthermore the asso-
ciation with effort sets these episodes apart
from the usual carotid sinus reflex. A pos-
sible inability of the heart to increase out-
put to meet the sudden increase in circula-
tion demanded by exercise has already
been discussed.

The therapy of syncope in relationship to
heart disease depends primarily upon the
causative factors which require treatment.
Precardiac types, of course, require loosen-
ing of clothing and the assumption of the
horizontal position to promote increased
venous return. The failure to carry out this
procedure, as pointed out above, can be re-
sponsible for sudden death. If symptoms
are not quickly relieved, olfactory stimu-
lants and epinephrine and adrenalin-like
products are advocted as well. Atropine is
not helpful. In some instances artificial
respiration and 10 per cent carbon dioxide
in 90 per cent oxygen and cardiac massage
may be necessary. In the carotid sinus re-
flex, novocaine block and surgical proce-
dures are preventive measures as are ephe-
drine and related drugs in postural hypo-
tension.

In the cardiac type of syncope the pres-
ence or the absence of vagal effects is ex-
tremely important in the approach to ther-
apy. If the vagus is active, atropine in
doses of 1/60 grain will abort the attack.
This drug, or tincture of belladonna, may
be given regularly to prevent the develop-
ment of attacks in the susceptible, especially
those with hyperactive cartoid sinus re-
flex. In the organic type of Stokes-Ad-
ams attacks the most beneficial drug in
asystole or very slow heart is epinephrine.
It may be necessary to give this drug, in
the precardiac as well as in the cardiac type
of syncope in 1 :10,000 dilution intrave-
nously rather than in 1:1,000 dilution be-
cause of the impairment of circulation and
the inability to take the drug up when given
subcutaneously. Epinephrine may be nec-

Sodeman and Engelhardt — Causes of Syncope

315

essary by intracardiac injection in Stokes-
Adams syndrome. Again, in the prevention
of such attacks, adrenalin-like products,
which may be given by mouth, such as ephe-
drine in 3/8 grain doses, are effective.
Thyroid substance has been advocated to
increase the irritability of the heart and
also prevent the development of such at-
tacks. It is given by mouth in the usual
doses. Barium chloride we have not found
to be beneficial. Epinephrine is also bene-
ficial in those episodes of complete heart
block with shift of the pacemaker and the
institution of a markedly lowered ventricu-
lar rate. Epinephrine increases the irrita-
bility of the heart muscle and steps up dis-
charge of impulses from the pacemaker. A
word of caution must be added about the
use of epinephrine in Stokes-Adams syn-
drome. Rarely, but at times, such episodes
may result from transient attacks of ven-
tricular fibrillation. Under this circum-
stance the administration of epinephrine
may aggravate the ventricular fibrillation
or bring on an episode when not present at
the time. This drug, therefore, may be re-
sponsible for the death of the patient under
these circumstances. Parenthetically, we
might state here that epinephrine is also
contraindicated in central vasomotor syn-
cope due to local anesthesia for the drugs
are synergistic. Here, barbiturates are in
order.

In the cardiac type of syncope that may
rest upon extreme tachycardias, the thera-
peutic indications are those of these condi-
tions.

In the postcardiac type of syncope the
cause is treated if possible. In that related
to angina pectoris and aortic stenosis, there
is no adequate form of treatment to com-
bat the development of syncope on exer-
tion. In patients with angina the use of
dilator drugs, such as nitroglycerine, has
been found to benefit the syncope as it re-
lieves the pain. In aortic stenosis, as well
as in angina, the most important procedure
in prolonged syncope is to control the de-
gree of exertion with which these attacks
are brought on.

CONCLUSIONS

In conclusion, we may say that syncope
may be classified into three groups depend-
ing not upon the mechanism of production
but upon the state of the cardiovascular
system resulting from the mechanisms pro-
ducing the syncope. This classification is
of help in the differential diagnosis and
the approach to the treatment of syncopal
attacks. Heart disease may be responsible
for syncope in any of these groups and a
careful evaluation of the patient after an
examination to establish the nature of the
episodes, is necessary not only for a ra-
tional approach to treatment but to elimi-
nate the dangers of certain therapeutic pro-
cedures commonly used in such patients.

REFERENCES

1. Weiss, S. : Syncope and Related Syndromes. In Oxford
Medicine, Vol. 2. P. 250 (9), Edited by H. Christian. New
York : Oxford University Press, 1940.

2. Nathanson, M. II. : Pathology and pharmacology of
cardiac syncope and sudden death, Arch. Int. Med., 58 :G85,
193G.

3. Cookson, H. : Fainting and fits in cardiac infarction.
Brit. Heart J., 4 :163, 1942.

4. Comeau, W. J. : A mechanism for syncopal attacks
associated with paroxysmal auricular fibrillation, New Eng-
land ,T. M.. 227:134, 1942.

5. White, P. D. : Heart Disease. 2nd Ed. New York. The
Macmillan Co., 1942.

0. Gallavardin, :L. : Angine de poitrine et syndrome de
Stokes-Adams : Acees angineux a forme syncopal, Press
Med., 30 :755, 1922.

7. Gallavardin, L., and Rougier, Z. : Acces d'angine de
potrine avec hypotension arterielle extreme et accidents
nerveux syncopaux et cpilcptiformes, Paris Med., 2 :15,
1928.

8. Gallavardin, L. : Syncopes d’effort dans le retrecis-
sement aortique, Le Medicine, 1C :197, 1935.

9. Gravier, L. : Syncope d’effort au cours d’acces angin-
eux et retrecissement aortique, .T. med. de Lyon, 17 :615,
1 936.

10. Contralto, A. W., and Levine, S. A. : Aortic stenosis
with special reference to angina pectoris and syncope,
Ann. Int. Med., 10 :103G, 1937.

11. Marvin, II. M., and Sullivan, A. G. : Clinical observa-
tions upon syncope and sudden death in aortic stenosis,
Am. Heart .L, 10 :705, 1935.

DISCUSSION

Dr. H. T. Engelhardt (New Orleans) : There are
certainly few acute clinical manifestations which
present a more alarming- and more startling- pic-
ture than syncope.

As we have pointed out, syncope is not the re-
sult of a single mechanism but rather a number of
disturbances are responsible for the occurrence
of the syndrone. It is impossible to dwell at length
upon the differential diagnosis but we think it is
important to emphasize the similarity of syncope,
particularly the postcardiac type, with that of
epilepsy. It will be appreciated that syncope may
be preceded by aurae, and that fainting may be
accompanied by convulsions. A comparison of the

316

Sodeman and Engelhardt — Causes of Syncope

features of syncope with those of epilepsy serves
only to emphasize their similarity. In the last
analysis it is only by weighing- the evidence in
favor of each that a specific diagnosis is reached.

When the pathogenesis of the attacks is not
clear — epilepsy is likely, because in the majority of
cases, detailed investigation usually reveals the
cause of syncope, and by the same token, noc-
turnal attacks, aurae of long duration, especially
olfactory aurae, are important bits of information
in favor of epilepsy. Convulsions with little pro-
dromata and biting of the tongue are also findings
of importance in epilepsy. There is usually a fall
in blood pressure in syncope, of the precardiac
and cardiac varieties, a slow pulse and rapid re-
covery from the attacks; these are usually not
found in epilepsy. The diagnosis of postcardiac
syncope from that of epilepsy is at times a par-
ticularly difficult differentiation to make. In the
types of syncope which can be reproduced ex-
perimentally such as the cerebral type of carotid
sinus reflex, electro-encephalographic studies have
shown that the convulsive distui-bances are not
those of epilepsy.

We feel that the differential diagnosis of syn-
cope is assisted by a division into precardiac, card-
iac and postcardiac varieties.

This classification is by no means complete and
final but we believe that it makes for a clearer
understanding of the subject and is a real aid in
organizing a logical therapeutic approach to the
problems.

Dr. J. H. Musser (New Orleans) : Syncope is a
condition that varies in intensity and severity. As
Dr. Sodeman brought out, in some instances it
may result in the death of the patient. On the
contrary it is also quite possible that the patient
may simply complain of occasional dizzy attacks
or a feeling of weakness, rather transitory in
character, and then come to the doctor for advice
and recommendations. The more severe forms are
so outstanding that there is no doubt the doctor
would make every effort to determine the cause
of fainting or of prolonged unconsciousness. On the
other hand in mild attacks he should not dismiss the
patient with the comment that the blood pressure
is abnormal or that the brain does not get the
blood at the right time or something soothing of
that sort; the mild attack of today may be the
severe one of tomorrow so that early recognition
is of prime importance.

Dr. A. A. Herold (Shreveport) : This is quite an
interesting presentation by Dr. Sodeman and Dr.
Engelhardt. especially in reference to precardiac
and postcardiac cases. I could not help but think
of a patient, the type of which Dr. Sodeman
stressed, the Stokes-Adams syndrome, whom I had
a few years ago. The patient was brought in to
me, sometimes, a few days or weeks apart, com-
pletely comatose; complete attack of 'Syncope,
pulse rate of forty or less and usually with a gash
on the head. A real severe head injury convinced

him of the seriousness of his condition. We finally
put him to bed from which he did not get up.

There are other causes, of course, of syncope.
As I understand it, this paper especially refers to
the heart. One which should not be overlooked is
syncope from induced or spontaneous hypogly-
cemia. For example, the patient is walking along
the street, feels the effects of insulin and falls
out. That certainly can not come under this head-
ing or the heading of epilepsy. For several years
attempts have been made to prove that hyper-
insulinism attacks are the same as epilepsy but
this is not true. I think this paper is worthy of
study and I intend to study it when it is published
in the Journal. There are so many things brought
out and there is not time enough allowed for pro-
longed discussion. It will do us good to make a
careful analysis of Dr. Sodeman’s and Dr. Engel
hardt’s remarks.

Dr. J. E. Knighton, Sr. (Shreveport) : The es-
sayists have referred to attacks of syncope asso-
ciated with convulsive seizures and Dr. Herold
mentioned the fact that we sometimes see attacks
of apparent syncope associated with hypoglycemia.
I think it is very well to think of this possibility
for the simple reason that there are some very
definite diagnostic features in connection with
that condition that are probably not associated
with syncope of other types. For instance, the
syncope associated with hypoglycemia does not,
as a rule, occur in instances such as pointed out
by Dr. Herold but most frequently we see those
attacks early in the morning; frequently before
the patient has gotten out of bed and without any
physical effort whatever. That is at the period, of
course, when the blood sugar is at its lowest
point. Associated with the symptom of syncope
and convulsive seizures, we usually have marked
tremor and excessive sweating, absolutely wet
all over with perspiration. Usually a very careful
study of the patient’s history will give suggestions
of this probable condition and we should think of
those things as possibilities.

Dr. T. A. Watters (New Orleans) : I welcome
this paper, as a neurologist, because I think it is a
simple, practical classification of many of the
syncopes that we see in our field. One of the
most frequent complaints we get among nervous
patients is “spells” and sometimes it is quite try-
ing to work out not only the psychology but the
physiology of these “spells.” Dr. Sodeman has
seen several cases with me and we have had
trouble in determing what is in operation in these
patients with “spells.” I remember one or two
years ago I saw a patient Dr. Musser had seen and
had gone over. It was a very interesting case. A
woman, college graduate, married to a college
graduate, with several degrees. They were at one
another’s necks. She said she had been having
spells and came to see us. At first we thought it
was hysteria. It seemed that this woman descended
from one level of adjustment to another, from

McLaurin — Dissecting Aneurysm

317

intellectual to emotional. She threw one fit, which
went further than anticipated, by showing the
classical convulsive pattern. It is conceivable that
convulsions are defense mechanisms. In the animal
kingdom there are a group of animals that devour
their prey, in hot blood after the kill. Another
group wait until their prey is dead, cooled off,
and smells before they eat it. In this biological
theory the prey when faced with a situation from
which he can not escape or faced with an enemy
he can not successfully attack, develops uncon-
sciousness, syncope or convulses. Certainly this is
frightening to many animals and thereby defends
the convulsing organism.

Convulsions do a nice trick. For many years at
Charity Hospital I have seen several such cases
brought in as epileptics. There are prevalent many
superstitions and fears about convulsions. Many
police are fearful and stand in awe of an epileptic.
Several may pool their efforts to bring the patient
to the hospital. On the other hand, these same
policemen will capture a dangerous criminal, often
single-handed. However, when convulsions are in-
volved, superstition overtakes rationality.

During the era of insulin we have learned much.
We know, for example, there are variations and
degrees of convulsions; they aren’t all alike.

Several times a week we induce convulsions in
schizophrenic and depressed patients. The whole
matter of convulsions to us is a changing picture.
We have the electroencephalogram today, giving-
new insights into interpretations of epileptic dis-
orders.

This paper recognizes the integration between
mind and body, and what operates in the cardiac
system in relation to what is going on in the ner-
vous system — particularly consciousness. What the
authors have mentioned about epilepsy is indeed
important to us who practice psychiatry.

Dr. W. A. Sodeman (in closing) : There are sev-
eral things that are a little confusing in discus-
sions you might read about syncope. The first is
the relationship to shock as a term commonly
used to designate a state resulting from trauma
and so on. Syncope, the way we use the term, is
sudden, transient loss of consciousness. It may
accompany shock, so one cannot differentiate it
from shock as stated in the texts. One may dif-
ferentiate the syncope of shock from certain other
types of syncope, for example common fainting at-
tacks.

I did not have time to mention the occurrence
of syncope in relationship to use of drugs. Of the
drugs used in cardiac patients nitrates are most
likely to instigate syncope. Individuals given ni-
trates may develop fainting attacks while stand-
ing and are relieved when lying down.

Dr. Engelhardt’s remarks on epilepsy in rela-
tion to syncope are important, particularly with
the convulsive disorders which occur in the car-
diac and postcardiad types. The milder forms
which Dr. Musser mentioned are often confused

with syncopal episodes. Dr. Musser mentioned the
fact that sometimes episodes of syncope are ex-
tremely marked. Patients at times, when ap-
proached with a needle develop an attack of faint-
ing because of the fact that they are going to be'
stuck. Sometimes after an injection is given the
attacks are so severe that there is confusion as to
the cause. They may be so dramatic and so intense
that after parenteral injections they have been in-
terpreted as anaphylaxis rather than syncope.

Dr. Herold’s remarks on hypoglycemia giving-
syncope not upon a vascular basis but on some bio-
chemical basis, are interesting and true. This
means that syncope is not always related to. cere-
bral circulation as far as we can measure it. In
some cases which have been studied it has been
impossible to show any total change in cerebral
circulation. There are local changes but how- they
are brought about is not clear. They apparently
occur in the mid-brain and the center of conscious-
ness in that area is affected.

Dr. Knighton’s remarks on diagnostic measures
and hypoglycemia are important in differentiating
attacks.

Dr. Watter’s remarks in reference to “spells”
are very important because of the fact that pa-
tients who do have these episodes are very diffi-
cult to analyze and at times difficult to trace down
as to the cause of attacks. If we do not make at-
tempts to determine the type of syncopal attack
which occurs particularly in the milder forms, we
may be treating an individual for some state which
he does not have when he does have some type
which another treatment or procedure w-ould ter-
minate for him.

Nothing was said about simulated syncopal at-
tacks; in patients who pretend to have attacks of
syncope simple stimuli will let you know they have
not fainted but are pretending.

0

DISSECTING ANEURYSM OF THE
AORTA IN A BOY
J. W. McLAURIN, M. D.

Baton Rouge, La.

Dissecting aneurysm of the aorta has
been known to pathologists for many years,
the first complete report, according to Sai-
ler1, being made in 1708. In 1935, Gurin,
Bulmer, and Derby2 reported on 18 of 7,000
patients seen at the Massachusetts General
Hospital, in none of whom had the condi-
tion been identified before death. T. Shen-
nan3, in his thorough study, gives no
reports of cases younger than the third
decade of life, while Klotz and Simpson4,
although tabulating two cases from one to
ten years of age and seven cases from

318

Me L au Ri N — D iss ectincj A ne urys m

eleven to twenty years of age, confine their
case reports to cases ranging from 23 to 54
years of age. Schattenberg and Ziskind0,
writing in 1938, say: “It may occur at any
age,” a statement in which all writers on
the subject agree. Before the Southern Sec-
tion of the Otological, Rhinological, and
Laryngological Society, in 1937, two cases
were reported in which bronchoscopic ex-
amination had been done to determine the
cause of dyspnea. The results were rupture
and death. The total number of published
cases is around five hundred, with only
about 33 having been diagnosed clinically.
The present case is reported because of the
age of the individual and because of the
relative infrequency with which the diagno-
sis is made antemortem. The reasons are
probably that there is no syndrome to fol-
low in diagnosis, and that the condition
closely simulates various intrathoracic and
intra-abdominal conditions.

When a patient presents: (1) Sudden on-
set of severe pain, with a history of hyper-
tension; (2) a rapid or enlarged heart, with
or without murmurs; (3) the presence of
shock; (4) slight fever or leukocytosis ; (5)
dyspnea and cyanosis; (6) variation in
pulse between upper and lower extremities
— then dissecting aneurysm of the aorta
should be considered in the differential
diagnosis.

CASE REPORT

M. M., a white male, aged 15 years, was seen
in the office on July 26, 1943. He complained of
a discharging left ear, with some pain, no tender-
ness, and a slight elevation of temperature. He
had recently (two weeks) been in bed with a “flu”
infection for which he was treated by his family
physician with “sulfa drugs.” He had a history of
acute nephritis at the age of six years, at which
time he had had an adenoidectomy and tonsillec-
tomy. There was no other history of serious illness
or accident.

Physical examination revealed a well nourished,
somewhat pale young male, not apparently ill. His
only ear, nose, and throat findings were a subacute
otitis media (left), with an inadequate central
perforation of the tympanum, and rhinitis, with
infected adenoid remnants.

Routine office procedures were carried out for
the rhinitis and adenoid infection, and a surgical
incision was made in the left tympanum. He was
instructed to return on July 28. The following day
his temperature was normal, his otalgia had sub-
sided, and his entire infection improved.

On July 28, while waiting for his appointment,
he suddenly complained of a severe pain in the
thoracic and upper lumbar region of the back, and
he was somewhat nauseated. Due to the severity
of the pain and the nausea, no nose or throat
treatment was given, and the ear only checked to
determine if the incision was adequate. He was
sent home and advised to have his family physi-
cian check his chest and urine. This was done, with
essentiality negative findings.

About 10 hours later the patient began to have
frequent short convulsions, accompanied by im-
paired vision. He was admitted to the hospital.
The ear, nose, and throat examinations were es-
sentially the same as earlier in the office. Exami-
nation of the chest presented no pathology. The
blood pressure was 170/110. The temperature,
pulse, and respiration were normal. The neuro-
logic examination presented no pathology. The eye-
grounds showed no findings other than moderate
engorgement of the retinal vessels. The spinal
fluid was clear, with three cells (lymphocytes).
The pressure was 34 mm. The patient had a total
of 13 convulsions, lasting from two to seven min-
utes, in the next 12 hours, two of them immedi-
ately following the spinal puncture. His pulse and
respiration remained good between convulsions. He
expired suddenly about 12 hours after admission to
the hospital and 23 hours after he first complained
of pain.

LABORATORY REPORTS

Urinalysis • Color, yellow; reaction, acid; spe-
cific gravity, 10.21; albumin, trace; sugar, nega-
tive; indican, negative; acetone, negative; diacetic
acid; positive; crystals, none; casts, few hyaline;
epithelium, small amount; pus cells, moderate
number; blood, many R.B.C.

Blood examination: Hemoglobin, 75 per cent;

color index, 8; erythrocytes, 4,770,000; leukocytes,
15,650; small lymphocytes, 8; large monocytes, 3;
polymorphonuclears, 87 ; eosinophiles, 2 ; no plas-
modia found; N.P.N., 42.8 mg. per 100 c. c.

Cerebrospinal Fluid: Source, lumbar puncture;

cell count, 3 lymphocytes.

On

admission Maximum Minimum

Temperature

98

100.2

98

Pulse

90

100

90

Respiration

22

26

22

NECROPSY

REPORT

The necropsy findings were essentially negative
with the following exceptions:

Pleural Cavity: The left pleural cavity is free

of fluid, exudates, and adhesions. The right, how-
ever, is almost completely filled by a large quan-
tity of clotted and unclotted blood which com-
presses the lung upward and toward the median
line. No exudates or adhesions are present.

Pericardial Cavity: The pericardial cavity con-

tains a normal quantity of straw-colored fluid. The
pericardium is smooth, white, glistening, and free of
exudates and adhesions. The translucent epicar-

Nelken — What Makes Medicine Psychosomatic?

319

dium reveals a slight deposit of sub-epicardial fat,
spreading into a thin layer over the base of the
ventricles, along the interventricular septum and
the course of the coronary vessels.

Heart: The heart appears somewhat larger

than normal; on section, however, through the
thickened myocardium, only those changes consist-
ent with hypertrophy are noted. There are no
structural valvular changes, nor developmental
anomalies present.

Aorta: The intimal structure is smooth, glis-

tening for the greater part, although here and
there are seen small, scarcely visible, yellowish
atheromatous plaques, particularly pronounced in
the arch. Two and one-half inches below the aortic
valve is a linear tear one-half inch in length.
From this point the blood column has dissected be-
tween the muscular layers of the aortic wall, ex-
tending below to the level of the diaphragm, and
above almost to the aortic valve. At the site of
the linear tear in the intima, perforation has oc-
curred, permitting the escape of blood through the
mediastinal tissues into the right thoracic cavity.

Kidneys : Both kidneys are larger than nor-

mal in size, pale, and opaque in appearance. Dif-
fusely scattered through the external surface as
well as in the cortical area, on section, are numer-
ous small punctate hemorrhages. The divisions of
the cut surfaces are well defined; no distortion or
destruction of the architectural detail is noted.
The calices and pelves show nothing of importance.

ANATOMICAL DIAGNOSIS

(1) Dissecting aneurysm of the aorta.

(2) Hemothorax, right.

(3) Subacute and chronic nephritis.

(4) Early atheromatous aortitis.

NEPHROSCOPIC DIAGNOSIS

Nephroscopic section of tissue removed at post
mortem examination shows only those changes con-
sistent with the gross pathology described above.

Comment: No definite diagnosis was made in

this case prior to death. We were attempting to
make a diagnosis on a nephritic basis, assuming
that the otitis media had exacerbated a latent
nephritis.

CONCLUSION

In all cases, regardless of age, of severe
pain in the thorax or abdomen that cannot
be easily explained on other bases, dissect-
ing aneurysm of the aorta should be con-
sidered, so that the patient’s slim chance
for survival shall not be lessened by un-
necessary procedures.

REFERENCES
(Referred to in Text)

Sailer, S. : Dissecting aneurysm of the aorta, Arch. Path.,
33 :704, 1942.

Gurin, David. Bulmer, ,T. IV., and Derby, Richard : Dis-
secting aneurysm of the aorta ; diagnosis and operative re-
lief of acute artelial obstruction due to this cause, New
York St. J M., 35:1200, 1935.

Shennan, T. : Dissecting aneurysms, Medical Research
Council Special Report Series 193, London, 1934, 43 pp.

Klotz. O., and Simpson, W. : Spontaneous rupture of the
aorta, Am. J. Med. Sci., 184 :455, 1932.

Schattenberg, H. J., and Ziskind J. : Dissecting aneurysms
of aorta, J. Lab. & Clin. Med., 24 :264, 1938.

REFERENCES
(Not Referred to in Text)

Rogers, Hobart : Dissecting aneurysm of the aorta, Am.
Heart J., 18 :67, 1939.

Levitt, A., Levy, D. 'S., and Cole, J. R. L. : Dissecting
aneurysm of aorta : ease report, J. Lab. & Clin. Med.,
20 :290. 1940.

Blackford, L. M., and Smith, Carter : Coronary throm--
bosis vs. dissecting aneurysm in differential diagnosis, J. A.
M. A., 109 :262, 1937.

Hirscbboeck, F. J., and Boman, P. G. : A case report of
dissecting aneurysm of the aorta, with distinctive x-ray
findings, Minnesota Med., 5 :724, 1922.

Samson, Paul C. : Dissecting aneurysms of the aorta, in-
cluding the traumatic type: three case reports., Ann. Int.
Med.. 5 :117, 1931.

Kellogg. F„ and Ileald, A. H. : Dissecting aneurysm of
the aorta : report of case diagnosed during life, J. A. M. A.,
100 :1157, 1933.

Lounsbury, .1. B. : Clinical diagnosis of dissecting

aneurysm of the aorta, Yale J. Biol. & Med., 7 :209, 1935.

O

WHAT MAKES MEDICINE
PSYCHOSOMATIC?

SAM NELKEN, M. D.

New Orleans

In medicine, as in science generally, the
great strides of progress follow the discov-
eries of new tools. These tools are not only
apparatuses, like the microscope and the
x-ray; they are also methods, like the cul-
tivation of micro-organisms ; and ideas, like
the cellular theory. Often the apparatus
and the idea are integrated into one, as the
microscope is with the cell theory. When
we get hold of a new tool, we proceed to
try it out on the old problems, to push its
use as far as is worthwhile; in so doing
we neglect for the time the problems which
will not yield to it.

For the past half-century and more, we
in medicine have been exploiting a mar-
velous set of tools, and reaping almost un-
dreamed-of victories over human ills by
our use of the microscope, the chemical
laboratory, and other means with which
you are all familiar. Some of us were a
little dazzled by these successes, and be-
lieved that these tools would conquer all
ills if used intensively and skillfully

^Presented at the Interdepartmental Seminar,
Louisiana State University Medical School, June
28, 1944.

320

Nelken — What Makes Medicine Psychosomatic ?

enough; all disease was supposed to be ba-
sically a matter of cellular pathology. Oth-
ers, wanting naturally to help as many peo-
ple as quickly as possible, tacitly aban-
doned the attempt to find out exactly what
was wrong with the patients they saw;1
they tried instead to find in each patient
something that they already understood,
some cellular pathology that could be
treated by their wonderful tools. Often,
like Procrustes, they forced the patient to
fit their methods without much regard for
his actual troubles. These errors, made
with good intentions, brought pain and
loss nevertheless ; those who made them
could not avoid seeing that something
was wrong, but they were often so blinded
by the successes of their methods that they
blamed the patients for the failures. Some
were even angry, as if the patients they
could not help were playing some kind of
a practical joke on them. But, of course,
no set of tools is omnipotent; we were
bound to come against the limits of ours,
and the more vigorously we exploited them,
the sooner their limits would be reached,
and our pretensions humbled. These fail-
ures meant that new tools, new methods,
new ideas were needed; that the scope of
medicine had to expand not merely fur-
ther, but in new directions.

Gradually it began to be borne in upon
us that these bodies we were dealing with
were not just complex assemblies of cells,
tissues, organs, and systems, driven and
determined by their parts; we came to real-
ize more and more, as we lifted our tired
eyes from the microscopes and looked out
past rows of test tubes, that these bodies
belonged to people who lived complicated
lives among other people, and that they
used and abused their bodies and the vari-
ous parts of them in all kinds of ways.
Standing before this new view of our prob-
lems, we find at hand the new method, the
new tool with which to carry on the attack ;
it was devised and developed by a man who
began his medical research with the phar-
macology of cocaine, who was among the
very first to see how medicine had to ex-
pand, who became the Vesalius, Harvey,

Pasteur, and Virchow of psychiatry:
Sigmund Freud, the discoverer of psycho-
analysis. The use of his method or a modi-
fication of it enables us to learn, from
speech, gestures, and actions, the charac-
teristic ways in which our patients use their
bodies for work, for pleasure, and for the
emotional expressions and communications
which relate them to other people. In par-
ticular, we have learned a good deal abowt
the enormously varied bodily expressions of
emotion and their relations to some other-
wise unexplained types of lesions, and about
people’s reasons for wanting to be ill or in-
jured which compensate for the disadvan-
tages; and about treatment directed at peo-
ple’s habits of misusing their bodies, in-
stead of merely at the structural results or
by-products of that misuse. This new and
growing understanding, integrated with all
the old and still-growing understanding,
constitutes the field which is now called
psychosomatic medicine, and which will in
future, I trust, be simply and properly
called medicine.

So much for the broad outlines ; but, you
will want to know, in this expansion of the
medical subject-matter, . what becomes of
the history, the physical examination, the
laboratory work, the treatment in ward or
clinic? Well, they expand also — not merely
by addition of new elements, but by rein-
tegration and embodiment of the advance
in understanding.

For one thing, the history and physical
examination are combined to a greater de-
gree than before. Good physicians always
began to inspect the patient as soon as he
came in, and knew that some bits of the his-
tory might be brought out during and after
the physical examination, for various rea-
sons. In psychosomatic examination, we
are alert to all the hints of feeling which
are in the patient’s way of presenting him-
self and his problem ; these concern us be-
cause his emotional attitude toward the
physician is of first importance in under-
standing his trouble, in treatment, and in
evaluating the results. We note his way of
telling his story, the changes in voice, face,
and gesture which have emotional meaning.

Nelken — What Makes Medicine Psychosomatic ?

321

the pauses, sharp changes in train of
thought, corrections, contradictions ; we
ask ourselves “How is he trying to get me
to feel toward him ? What does he want of
me besides what he appears to?”; in short,
we are watching for evidences of ulterior
motives, for indirect expressions, for hints,
for underlying trends, as well as seeing
what the patient intends us to. We let him
tell his story in his own way; and this is
less boring in psychosomatic examination,
because his verbosity, circumstantiality,
and seemingly irrelevant details now are
seen to have meaning in the whole picture.
The physical examination begins with the
handshake when the patient enters ; we can
learn to tell a lot from this physical con-
tact, beginning with what we already gath-
er half-intuitively from it. When someone
crushes your hand, you know at least vague-
ly that he has aggressive and domineering-
tendencies; and you feel at least vaguely
resentful of being overpowered in this small
way; but you probably do not wonder, un-
less you have thought about the intricacies
of human expression, what timidity the
hand-crusher is trying to conceal behind
this bold front. Such timidity and its dis-
guise may be highly important factors in
his trouble. Our observations of facial ex-
pression, gesture, blushing, or sweating,
during the history taking are physical ex-
amination by inspection. We also watch for
evidences of somatic muscular tension and
relaxation; and in the formally physical
part of the examination we ask the patient
to relax, note whether he can, and what
feelings or thoughts he expresses while try-
ing, because people often use muscular ten-
sion to suppress painful thoughts, e. g. :
in gritting their teeth. We are, of course,
interested greatly in autonomic behavior ;
and we note carefully the patient’s emo-
tional response to undressing, to being han-
dled, being looked at, and any special re-
actions associated with the examination of
particular parts and defects. Quite com-
monly the patient will be reminded of ad-
ditions to the history by some part of the
physical examination, and the connection
will usually be interesting; often patients

become considerably franker after they
have undressed and relaxed — a sort of
psychological undressing — and add to the
history, or correct it, in highly significant
ways. These are things which you have
probably all noticed from time to time; the
psychosomatic point of view endows them
with full meaning, and integrates them
with the other findings in our understand-
ing, as they are already integrated in the
patient himself.

From the psychosomatic point of view
we are interested not only in the effect of
emotional states on the commonly reported
laboratory findings, such as blood and urine
sugar, basal metabolic rate, and so on, but
in the reactions of the patient to the asso-
ciated procedures, such as being stuck with
a needle, having to breathe with a slight
effort through the mouth while the nose
is fastened shut, having to lie quiet for
some time. These responses indicate to us
the presence or absence of anxieties which
may be of great importance in the under-
standing and handling of the patient’s trou-
bles. There are some people, for instance,
who actually rest less if they are kept in
bed than if they are allowed to be up and
about a little; they have intense anxiety
expressing itself in mild agitation, and if
they have to be quiet they just “burn up”
internally. Sedation helps these people
sometimes, but psychotherapy directed at
the sources of the anxiety is the treatment
of choice.

Psychosomatic therapy consists, in gen-
eral, of treating the patient’s habitual mis-
use of his body along with the treatment
of the resulting lesions or intercurrent dis-
eases. Such misuse, no less than normal
use, achieves something of value for the
patient; this is a point which must never
be overlooked. Psychotherapy, then, must
help the patient to find other methods, oth-
er aims, which are less costly and harmful
and more valuable, which we call normal.
As the patient talks more or less frankly
about himself and his troubles, the com-
paratively unbiased psychotherapist is able
to recognize and call to his attention re-
pressed wishes and tendencies which he has

322

D’Ingianni — Intestinal Obstruction

unconsciously been gi'atifying to some ex-
tent by the very behavior or symptoms of
which he complained; this gratification is
his gain from the illness. When the patient
becomes aware that he is largely or entirely
producing his troubles himself to satisfy
previously unconscious needs, he is in a
position to substitute methods or aims
which are more reasonable, less costly, and
altogether far more satisfactory to him and
to others around him. In many cases he
gains this awareness quite readily; these
are cases which will eventually constitute
minor psychiatry, to be handled by ade-
quately trained general practitioners just
as minor surgery is. Other cases will be
analogous to severe orthopedic problems,
will require prolonged and deft psycho-
therapeutic handling, and will have to be
treated by specialists. Psychosomatic treat-
ment, howrever, employs psychotherapy as
one of its tools, to be integrated in use with
the whole armamentarium of medicine and
surgery; a perforated peptic ulcer will, of
course, be treated surgically, and psycho-
therapy will be used against the sources of
the gastric over-activity to avert the recur-
rence. Medical treatment of gastric ulcers
will be judiciously combined with psycho-
therapy by physicians who realize that
abandonment of responsibility, going to
bed, and dieting on milk and cream consti-
tute a return to an infantile way of life, a
regression; and who recognize the psycho-
logical advantages and disadvantages of
this regime as well as they do its buffering
of acid.

In closing, I want to point out that the
main obstacle to the development of medi-
cine in the psychosomatic direction is prob-
ably in the attitude of physicians them-
selves, in their traditional and almost un-
conscious overlooking of emotional factors
in patients, especially the emotional advan-
tages of illness which are so important in
neuroses and psychosomatic conditions.
As an interesting but distressing effect of
overlooking one sees in the clinics many
chronically neurotic patients who have been
so to speak “organically trained,” genera-
tions of bored residents and interns taught

them that the doctor is not interested in
their emotions nor in any troubles without
bodily localization. Since coming to the hos-
pital was emotionally valuable to them, they
acquiesced in this, and translated most of
their personal problems into organ-lan-
guage, a sort of medical double-talk which
sounds like disease but does not fit recog-
nized entities. These people, as you know,
are a heavy burden to the hospital, espe-
cially as they are not really being treated
or cured, but only getting a perverse kind
of pleasure out of hospital care to take the
place of some normal satisfactions which
their lives lack. The maturing of psycho-
somatic medicine promises to abolish this
troublesome and unhappy group of patients
by understanding and treating their actual
problems, rather than taking the neurotic
disguise as the whole truth. Its new tools
and new ideas should relieve many head-
aches of both patients and physicians for
which no remedy was known before.
o

INTESTIONAL OBSTRUCTION
FOLLOWING THE USE
OF COTTON

CASE REPORT

VINCENTE D’INGIANNI, M. D.+

New Orleans

A great deal has been written on the
technic of closing wounds with cotton,
stressing size of suture material, and the
method by which it should be implanted;
but nothing has been said of the danger of
leaving long ends of the suture material
in the abdomen or on objects that are to be
placed in the abdomen. In interrupted
suturing the clippings multiply and meticu-
lous care must be exercised to prevent their
being carried into the wound.

This case is being reported because one
of these pieces of cotton found its way into
the abdomen and caused intestinal obstruc-
tion :

CASE REPORT

I. M., a white female, aged 21, had had an ap-
pendectomy in 1940 and cotton was used in the
procedure. On January 9, 1943, she was taken

tFrom the French Hospital.

D’Ingianni — Intestinal Obstruction

323

with severe abdominal pain and vomiting. The
following day she was admitted to the hospital,
where a diagnosis of intestinal obstruction was
made, clinically and roentgenologically. She was
prepared for an operation. Inspection of the peri-
toneal cavity revealed collapse of the ileum and of
a portion of the jejunum with dilatation above the
constricted area. Exploration of this area revealed
a band circumscribing the gut, the ends of which
attached to the mesentery. When the band was re-
moved it had the appearance of a piece of cotton.
It was studied microscopically and verified as
such.

DISCUSSION

It becomes essential, when cotton is used,
that there be some definite place on the op-
erating field for a receptacle wherein all
free ends of cotton might be discarded.
Also, if all sutures were left long until each
particular phase of surgery had been com-
pleted, all suture ends could be disposed of
simultaneously.

BUY WAR BONDS

324

Editorials

NEW ORLEANS

Med ical and Surgical Journal

Established 18UU

Published by the Louisiana State Medical Society
undei' the jurisdiction of the following named
Journal Committee:

Val H. Fuchs, M. D., Ex officio
For two years: G. C. Anderson, M. D., Chairman
Leon J. Menville, M. D.

For one year: J. K. Howies, M. D., Vice-Chairman
For three years: C. Grenes Cole, M. D., Secretary
E. L. Leckert, M. D.

EDITORIAL STAFF

John H. Musser, M. D Editor-in-Chief

Willard R. Wirth, M. D. Editor

Daniel J. Murphy, _ M. D. Associate Editor

COLLABORATORS— COUNCILORS
Edwin L. Zander, M. D.

J. T. O’Ferrall, M. D.

Guy R. Jones, M. D.

T. B. Tooke, Sr., M. D.

George Wright, M. D.

W. E. Barker, Jr., M. D.

C. A. Martin, M. D.

W. F. Couvillion, M. D.

Paul T. Talbot, M. D General Manager

1430 Tulane Avenue

SUBSCRIPTION TERMS-' $3.00 per year in ad-
vance, postage paid, for the United States; $3.50
per year for all foreign countries belonging to the
Postal Union.

News material for publication should be received
not later than the eighteenth of the month preced-
ing publication. Orders for reprints must be sent
in duplicate when returning galley proof.

Manuscripts should be addressed to the Editor,
H30 Tulane Avenue, New Orleans, La.

The Journal does not hold itself responsible for
statements made by any contributor.

THE NEW YEAR

We trust that our readers have had, in
spite of these parlous times, a satisfactory
and completely cheerful Christmas. For
the New Year we wish you all good health
and happiness, although we realize that with
the horrible war going on no one can feel
truly happy and in the homes of many
there resides sadness and unhappiness.

What this new year will bring forth no
one can predict. Six months ago we felt
that the conquest of Germany would have

been accomplished by now. Instead of vic-
tory over the Hun, we are now facing the
prospect of a long continued struggle with
an enemy who was always dangerous, who
fights with courage and tenacity and who is
a foe not to be underestimated. The tragedy
of the war, as with all wars, is the killing
and maiming of the best of our young citi-
zenry. When we read the accounts of the
deaths in action of the young men who have
just completed many years of arduous study
and work in preparing themselves to be
physicians, we can appreciate best the ter-
rible toll that war takes. May this horrible
world-wide conflict be over in the near fu-
ture is the best wish that any American can
have, irrespective of whether or not his
sons and daughters are in the conflict or
whether he has dear ones close to him who
may be killed or permanently crippled.

o

HEALTH INSURANCE

The magazine Time reports accurately
and fairly the numerous developments of
medical science and medical economics. As
a matter of fact, there are many doctors,
reading the section entitled “Medicine,”
who receive the first inkling of changes or
of recent discoveries that have taken place
in the field of medicine. This is no reflec-
tion on the physician because it would be
impossible for him to take and read every
medical journal that is published. How-
ever fairly Time usually may be, the ac-
count entitled “The Big Debate”, which has
to do with a recent meeting of the National
Physicians’ Committee, in some respects is
somewhat unfair to the physician, although
on the whole the report is without serious
prejudices.

Time points out that the opposition to the
Wagner-Murray-Dingell Bill is principally
“the conservative American Medical Asso-
ciation.” It also notes that a survey by the
Opinion Research Corporation found that
only 37 per cent of people favor “a Federal
Government plan” for health security.
Another survey, made by a different group,
found that 68 per cent of people favor a
broadened social security law which would

Editorials

325

cover payments for a physician, as well as
hospital care. These surveys certainly leave
the unprejudiced reader with the idea that
there is not a tremendous demand by the
population for any great modification of the
present type of personal medical care. Time
says that reformers and organized labor
are the people who are backing the Wagner
Bill. The latter groups claim several things
which the thoughtful medical man knows
is not true: (l)that the standards of medi-
cal care would be raised by the provi-
sions of the Wagner-Murray-Dingell Bill;
this is extremely doubtful, and (2) that
there are well populated parts of the United
States where the needy cannot get, at the
present time, adequate medical care. This
argument for the Bill is also one based on
false premises. A man living in the wilds
of Montana, where the population might be
five people per square mile, irrespective of
his worldly goods, assuredly could not im-
mediately obtain a doctor to repair a rup-
tured appendix. It is also true that he
would not be able to find at once a mechanic
to fix his automobile if there was a serious
injury to that piece of machinery. The
needy have little to do with the arguments
for socialized medicine. The needy are
people who can and do obtain, even in the
smaller communities, the very best medical
care given by the same physicians who treat
the wealthy and who are hospitalized,
where it is true they do not have private
rooms, and do have to sleep in a ward. The
so-called rebuttal to the physician’s claims
we think misses the best argument that
there may be for a medical insurance act,
namely that those persons most likely to
suffer from lack of adequate medical at-
tention are those who are not needy but
are in the lower income group. If these
people do suffer, however, it is largely be-
cause of false pride. Practically every
physician is willing to make his fees meet
the pocketbook of the patient and certainly
the cost of hospitalization has been taken
care of most satisfactorily by hospital in-
surance, which is being quite universally
bought by people' over the entire country.

Two very pointed arguments against this

pernicious Bill are not mentioned: (1) that
labor would object very strenuously to hav-
ing a 6 per cent cut in its wages to pay for
health insurance, and (2) that the cost of
medical service would be immeasurably in-
creased because of the necessity to support
untold thousands of lay bureaucrats who,
the thinking physician feels, would attempt
to control medicine in the United States.
Both of these statements are valid. The
last one is substantiated by Time because it
notes in its article that in the survey in
which only 37 per cent of those questioned
wanted a Government plan, “people tend to
say No when confronted by phrases like
‘Federal Government’.” We have too much
Federal Government at the present time and
if this Bill should pass we would have a
whole lot more.

The last sentence of this article is so ob-
viously incorrect that it hardly needs to be
countered. The sentence states that “this
spurt in A.M.A. thinking” (development of
a satisfactory plan of group medicine) “ac-
cording to some critical observers brought
the organization up to 20 years behind the
times.” As a matter of fact the organiza-
tion and its membership has been thinking
about, planning for, and has made effective
in many areas forms of medical practice
which were never heard of 20 years ago.
o

ATYPICAL PNEUMONIA

The term atypical pneumonia has come to
mean a systemic disorder usually associated
with lung pathology. The term atypical
pneumonia was coined because the disease
did not have the typical features of lobar
pneumonia. When this term was first used
the cases were few and the condition was
relatively rare. It had none of the charac-
teristics of lobar pneumonia; it was there-
fore spoken of as being unusual or atypical.
Now that the incidence of the disease far
exceeds that of lobar pneumonia of pneu-
mococcic origin, it might well be said that
this latter type of pneumonia is atypical
and the other type of viral origin is the
typical type seen nowadays. Illustrative of
the frequency with which this viral pneu-
monia occurs, are the reports from the

326

Editorial

State Board of Health that show at the
time this was written there have been re-
ported almost 1400 cases in the State of
Louisiana, as contrasted with less than 500
cases of pneumococcic pneumonia.

The cause of viral pneumonia is not
known; a variety of viruses have been im-
plicated. At the present time the most
likely group of viruses that may be the
etiologic agent include the viruses of parrot
psittacosis and pigeon psittacasis, ornitho-
sis. There is a close resemblance to the
Donovan virus of lymphogranuloma ven-
ereum and the virus meningopneumonitis.
Influenza A virus has also been incrimi-
nated, as well as the cotton rat virus which
at the present time seems to be quite pop-
ular as a possible etiologic factor. It may
be that any of these viruses or many more
may have pneumotropic activities which are
responsible for the production of the symp-
toms. Unfortunately the identity of cer-
tain viruses constitutes a laboratory- prob-
lem which cannot be handled except in a
few places with very elaborate equipment
and specially trained men. Bacterial dis-
eases can be identified by laboratory
measures in practically any reasonably well
equipped laboratory in the country.

No matter what the etiology might be of
this unusual pulmonary condition, there are
several clinical features which need to be
stressed. In the first place, the incubation
period is decidedly variable ; it may be from
48 hours to three weeks. The onset is by
no means characteristic. In patients with
a short incubation period the start of the
disease is usually abrupt with a chill or a
rigor and a prompt elevation of the fever
to 103-105 degrees. In the instance of a
long period of incubation the onset is grad-
ual, the presenting symptoms are often
those of a cold and tracheobronchitis. The
most frequent symptom aside from malaise,
which is associated with any infectious pro-
cess, is cough; this is present in approxi-
mately 85 per cent of patients. The sputum
is characteristic only in the absence of a
large number of bacteria of the coccal type.
A goodly number of patients suffer from
sore throat and likewise in about half of

the patients, particularly at the onset, the
headache is often extremely severe, so
severe that it may be mistaken for, in a
few instances, the head pain of a bacterial
meningitis. The physical signs are woe-
fully lacking. It is literally astounding in
some of the severe cases to find extensive
roentgenologic changes and yet the only
physical signs may be subcrepitant rales
induced only after coughing. The x-ray is
characteristic ; it is the one definite finding ;
the lung fields show involvement in the
hilar area extending out towards the peri-
phery, with a tendency when serial x-rays
are taken, to show progressive areas of in-
volvement in other places in the lung. The
x-ray findings may clear up within a few
days after the subsidence of fever or they
may persist for weeks after the patient is
clinically well.

Laboratory findings are of value from the
standpoint of their negativity. The sputum
discloses no predominance of any one bac-
terium, the leukocyte count is normal and
the differential formula is unchanged. If
the disease is prolonged there may develop
a slight leukocytosis, probably indicative of
secondary bacterial invasion.

Complications are few. The prognosis is
excellent. Even in the most severe camp
epidemics the death rate has been less than
one-fourth of one per cent.

The treatment again is negative. There
is no specific and the sulfonamides have no
effect on the course of the disease. As a
matter of fact, they are probably contrain-
dicated as of the complications that have
been reported many of them have been due
to the sulfonamides. Prolonged bed rest is
a definite requisite for the final recovery of
the patient, as recurrences are quite fre-
quent and may be obviated by rest in bed
and prolonged convalesence.

Physicians have been boasting of their
conquest of lobar pneumonia. Now there
appears a disease which, while rarely fatal,
is often incapacitating for many weeks.
Certainly medicine is not a static science.
If one disease is controlled another one
seems to take it place.

Organization Section

327

ORGANIZATION SECTION

The Executive Committee dedicates this page to the members of the Louisiana
State Medical Society, feeling that a proper discussion of salient issues will contri-
bute to the understanding and fortification of our Society.

An informed profession should be a wise one.

THE PROFESSION AND THE PUBLIC*

By this time the Wagner-Murray-Dingell
Bill should be thoroughly understood by
every doctor in the active practice of medi-
cine. Any one who is not familiar with its
full import should make every effort to
study it, and become fully cognizant of its
meaning. It is a Bill that would, without
any question of doubt, completely socialize
the practice of medicine. It would make
every doctor subservient to his ward boss
and political leader with all of these inher-
ent dangers. He would have to cater to the
ward boss rather than to his patient. It
would create a new class of political doc-
tors with all the evils of political practice,
which seeks emoluments while avoiding
burdens.

No longer would the personal relationship
between patient and doctor exist, and the
patient would simply become a pawn of the
State. No conscientious doctor would want
or desire to practice medicine when a third
party would intervene to tell him how and
what he might do for any patient. What
the American people want is the best of
medical services at a price that they can
afford or for which they can budget. They
do not want a minimum of advice and pre-
scription by a government-controlled doc-
tor not of their own choosing but paid by
tax money out of their own pay checks. The
American public must be shown that gov-
ernment-controlled medicine is, in the long
run, the most expensive of medical services.

The history of State medicine in every
country that uses it shows that under state
control, medicine has deteriorated. The
doctors of America can be proud of the
record which they have made in the fight
against disease ; the records speak for them-
selves. However, some plan must be de-
vised to help the individual meet his medical
expenses in the same way that an individual
provides for his family after his death, by

life insurance ; in the same way that an in-
dividual prepares for the unlooked-for hos-
pitalization of his family, by insurance ; in
the same way that an individual insures his
home, his automobile, and any of his per-
sonal belongings.

Quite a few states have already formed
prepayment medical plans and many others
are in the process of forming such plans.
The Louisiana State Medical Society has a
committee appointed to study the plan of
prepaid medical services. This is something
that we should go into seriously and con-
sider from every angle. And it should be
done now.

The individual should have every right to
budget his medical services just as he does
all other expenses, and we as medical men
should make every effort to meet this re-
quirement. A plan must be devised which
is satisfactory to both doctor and patient,
for I feel confident that the patient would
rather have a plan in which his own physi-
cian is interested than a plan which is gov-
erned and supervised by political bureau-
crats. If hospitalization can be made a suc-
cess, and many other States have plans for
prepaid medical services which are also suc-
cessful, then Louisiana should be able to
formulate a successful plan of prepayment
for medical services which would also be
satisfactory to both patients and doctors.

In this way, and only in this way, can the
Wagner-Murray-Dingell Bill be successfully
combated. We have been shown the way;
now we should act. Let us not be the first
to discard the old, nor yet the last to at-
tempt the new.

*The above was a message which appeared in a recent
issue of the Orleans Parish Medical Society Bulletin by Dr.
Val H. Fuchs President. Louisiana State Medical Society.

O

At the last meeting of the House of Del-
egates a special Committee on Pre-Payment
Medical Service was appointed for the pur-
pose of studying and preparing some con-

328

Orleans Parish Medical Society

crete facts for the State Medical Society in
regard to establishing in this state a volun-
tary pre-payment medical insurance. It
was generally felt in the House of Delegates
that such a plan would supply a definite
need for more equitable distribution of med-
ical care and would forestall the neces-
sity of Federal Government taking over the
practice of medicine.

This committee recently met in Alexan-
dria where representatives from every dis-
trict except two attended. There was a
liberal discussion of the various plans of
pre-payment medical insurance with jthe
idea of finding a suitable one which would
be applicable to the State of Louisiana. Un-
questionably, this committee will be pre-
pared to bring before the House of Dele-
gates of the State Society some definite con-
structive suggestions for their proper con-
sideration and deliberation. There are a
great many phases which have not yet been
completed in relation to this stupendous
problem. The chairman and the various
members of the committee evidenced by
their discussion a tremendous amount of

study and research which they have formu-
lated in order to reach some appropriate
decision as to what is best for the State of
Louisiana. There is a lot of work yet for
the committee. As their plans mature into
some more definite policies it would be pre-
mature to place any particular emphasis on
certain conclusions which they have reached
concerning this work. This information
should be of value to the officers and mem-
bers of our various parish societies in order
that they may give this problem the thought
and study which is required before defi-
nitely shaping a policy for the entire state.

We advise you to read and become in-
formed of the various plans in force in an
attempt to learn the differences between
the various forms of pre-payment insurance
which are now prevailing in our country.
This is essential if we are to decide finally
on a plan which will succeed in our State.
Nothing is yet sure in this regard, but we
should all give serious and conscientious
thought to this grave problem which is re-
garded as essential for extension of medi-
cal service to the needy in our state.

■o

TRANSACTIONS OF ORLEANS PARISH MEDICAL SOCIETY

CALENDAR OF MEETINGS

January 2.
January 3.

January 4.
January 8.

January 10.

January 11.
January 15.
January 16.

January 17.
January 18.

Eye, Ear, Nose and Throat Staff,
8 p. m.

Clinico-pathologic Conference, Ma-
rine Hospital, 7 :30 p. m.

Mercy Hospital Staff, 8 p. m.

Clinico-pathologic Conference, Tou-
ro Infirmary, 11:15 a. m.

Installation Meeting, Orleans Par-
ish Medical Society, Jung- Hotel,
7 p. m.

Touro Infirmary Staff, 8 p. m.

Woman’s Auxiliary, Orleans Parish
Medical Society, Orleans Club, 3
p. m.

New Orleans Hospital Council.

Hotel Dieu Staff, 8 p. m.

Charity Hospital Medical Staff, 8
p. m.

Clinico-pathologic Conference, Ma-
rine Hospital, 7 :30 p. m.

Charity Hospital Surgical Staff, 8
p. m.

Clinico-pathologic Conference, Tou-
ro Infirmary, 11:15 a. m.

January

19.

I. C. R. R. Hospital Staff, 12:30
p. m.

January

22.

Scientific Meeting, Orleans Parish
Medical Society, 8 p. m.

January

23.

Baptist Hospital Staff, 8 p. m.

January

24.

French Hospital Staff, 8 p. m.
Catholic Physicians’ Guild, 8 p. m

January

25

Clinico-pathologic Conference, Tou-
ro Infirmary, 11:45 a. m.

DePaul Sanitarium Staff, 8 p. m.

January

26.

L. S. U. Faculty Club, 8 p. m.

New Orleans Hospital Dispensary

for Women and Children Staff,
8 p. m.

January 31. Clinico-pathologic Conference, Ma-
rine Hospital, 7 :30 p. m.

During the month of January the Society will
hold two meetings; they are as follows:
JANUARY 8th

Installation Meeting. At this meeting the fol-
lowing officers for 1945 will be installed:

Dr. Daniel J. Murphy, President-Elect.

Dr. Philip H. Jones, Jr., First Vice-President.
Dr. Frank Chetta, Second Vice-President.

Orleans Parish Medical Society

329

Dr. H. Ashton Thomas, Third Vice-President.

Dr. Max M. Green, Secretary.

Dr. Paul G. Lacroix, Treasurer.

Dr. John R. Schenken, Librarian.

Dr. E. L. Leckert, Additional Member to the
Board.

Dr. E. J. Richard, Additional Member to the
Board.

Dr. A. V. Friedrichs, who was elected President-
Elect in 1944, will be installed as President for
1945.

JANUARY 22nd

Scientific and Fourth Quarterly Executive Meet-
ing. The following program will be presented:

Obstetric Analgesia — Dr. E. L. King.

Prenatal Care — Dr. Walter Levy.

Report of Officers and Committees

o

NEWS ITEMS

Drs. George Hauser, E. J. Richard, Waldo Treut-
ing and John M. Whitney attended the recent
meeting- of the American Public Health Associa-
tion in New York. Drs. Hauser and Treuting pre-
sented a paper entitled, “An Outbreak of Food
Poison Due to a New Etiological Agent — Salmon-
ella Berta.”

Dr. Milton E. Kirkpatrick discussed, “The His-
tory of the Movement of Mental Hygiene” at the
November meeting of the American Association
of University Women.

Dr. John M. Whitney was elected vice-chairman
of the Public Health Section of the Southern Med-
ican Association at the St. Louis meeting. Dr.
Whitney was recently elected first vice-president
of the Kiwanis Club.

Dr. Daniel J. Murphy has been elected to the
Board of Directors of the Mid-City Kiwanis Club.

Dr. W. Robyn Hardy, now overseas, has been
promoted from the rank of Major to that of
Lieutenant Colonel.

Dr. Waldemar Metz presented a dry clinic from
9 to 12 o’clock at the New Orleans Charity Hos-
pital on October 18, during the annual meeting
of the American Society of Plastic and Recon-
structive Surgery, of which he is one of the two
local members.

Dr. E. Carroll Faust lectured November 29 and
30 before the students and staff of the Army Med-
ical School in Washington, D. C. December 7 he
addressed the Mississippi Public Health Associa-
tion in Jackson.

At the November meeting of the Staff of the
Southern Baptist Hospital the entire program pe-
riod was devoted to the death report, as presented
by Dr. W. H. Gillentine. Of the 20 deaths, oper-
ation was performed in only one, and seven were
due to prematurity.

Dr. Alton Ochsner spoke at a meeting of mili-
tary surgeons in New York City on paravertebral
block for frostbites, and also participated in a
panel discussion on neurosurgical problems in the
armed forces.

At the December meeting of the Mercy Hospital
Staff, Dr. William H. Roeling presented a case
report, and Dr. L. A. Monte spoke on the diagnosis
and treatment of respiratory diseases. This meet-
ing being the last of the year, reports of various
committees were presented. It has been an-
nounced that the management of the Hospital has
purchased the site formerly occupied by Straight
University on Canal Street for a new hospital,
and that building will start as soon after the war
as it is possible to obtain material and equipment
for a modern, properly equipped structure.

Dr. Eugene Countiss and Dr. Julius Lane Wil-
son addressed a meeting of the Southwestern Di-
vision of the Alabama Medical Society at Golds-
boro, December 7.

Drs. Joseph A. Danna, James D. Rives, and Isi-
dore Cohn attended the meeting of the Southern
Surgical Association in Hot Springs, Virginia, De-
cember 5-7. En route they visited Ashford Gen-
eral Hospital in White Sulphur Springs.

Dr. Edwin L. Zander has been elected to the
Board of Directors of the New Orleans Associa-
tion of Commerce for the 3-year period 1945-47.

At the annual meeting of the American Society
of Tropical Medicine a resolution of thanks was
presented to Dr. Joseph S. D’Antoni, Secretary of
the Society, for his editorship and management of
Tropical Medicine News, the bi-monthly bulletin
established by the Society in February, 1944.

The following physicians participated in the
postgraduate review course in pediatrics offered
by the Tulane University School of Medicine, De-
cember 11-15: Dr. Emile Naef, Dr. Samuel B.
Nadler, Dr. Ralph Platou, Dr. Chester Stewart,
Dr. B. Bernard Weinstein.

Daniel J. Murphy, M. D.,

Secretary

330

Louisiana State Medical Society Netvs

LOUISIANA STATE MEDICAL SOCIETY NEWS

CALENDAR

Society

East Baton Rouge

Morehouse

Orleans

Ouachita

Rapides

Sabine

Second District

Shreveport

Vernon

PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS

Date

Second Wednesday of every month
Second Tuesday of every month
Second Monday of every month
First Thursday of every month
First Monday of every month
First Wednesday of every month
Third Thursday of every month
First Tuesday of every month
First Thursday of every month

Place

Baton Rouge
Bastrop
New Orleans
Monroe
Alexandria

Shreveport

EAST AND WEST FELICIANA BI-PRISH
MEDICAL SOCIETY

The Bi-Parish Medical Society met in East Lou-
isiana State Hospital. After an excellent dinner
served in the dining room members and guests
repaired to the staff room for a business session.
Program for the night was dispensed with, same
program to be given at our next meeting the first
Wednesday of March, 1945. Following officers
were elected for 1945: Dr. B. F. Smith, Jackson,

President; Dr. C. E. Sturm, Jackson, Vice-Presi-
dent; Dr. E. M. Toler, Clinton, Secretary-Treasur-
er. Delegates to the State Convention: Dr. E. M.
Toler, Clinton; Dr. Glenn J. Smith, Alternate;
Dr. E. M. Robards, Jackson, Pro-tem.

E. M. Toler, M. D., Secretary.

o

BEAUREGARD PARISH MEDICAL SOCIETY
At a recent meeting of the Beauregard Parish
Medical Society the following officers were elected
for the year 1945: President, Dr. Thos. R. Sartor;
Vice-President, Dr. Sam T. Roberts; Secretary-
Treasurer, Dr. J. D. Frazar; Delegate, Dr. Luke
Marcello; all of DeRidder.

o

POINTE COUPEE PARISH MEDICAL SOCIETY
The Pointe Coupee Parish Medical Society re-
cently elected the following officers to serve for
the year 1945: President, Dr. J. C. Roberts, New
Roads; Vice-President, Dr. J. W. Plauche, Mor-
ganza; Secretary-Treasurer, Dr. F. F. Rougon,
New Roads; Delegate, Dr. J. 0. St. Dizier, Walls.

o

MEETING OF THE COMMITTEE ON PRE-
PAYMENT MEDICAL SERVICE
On December 10 the Committee on Pre-Pay-
ment Medical Service met in an all day session in
Alexandria at the Hotel Bentley. Those in at-
tendance were as follows: Dr. 0. B. Owens, Chair-
man, Alexandria; Dr. Val H. Fuchs, President of
the Louisiana State Medical Society, New Or-
leans; Dr. E. L. Zander, President of the Orleans
Parish Medical Society, New Orleans; Dr. H. B.
Alsobrook, New Orleans; Dr. W. L. Bendel, Mon-
roe; Dr. H. W. Boggs, Shreveport; Dr. C. M. Hor-

ton, Franklin; Dr. P. T. Talbot, Secretary-Treas-
urer of the State Medical Society.

o

NEWS ITEMS

A physician is needed in Weeks, Louisiana. In
addition to a comfortable income, there is avail-
able a house for rent at $28 a month and free
office and equipment and lighting.

Dr. Joseph A. Danna, Clinical Professor of Sur-
gery, Dr. Isidore Cohn, Clinical Professor of Sur-
gery and Dr. J. D. Rives, Clinical Professor of
Surgery at Louisiana State University School of
Medicine attended the meeting of the Southern
Surgical Association in Hot Springs, Virginia, De-
cember 5, 6 and 7, 1944. En route they were
guests of the Army’s Ashford General Hospital
in White Sulphur Spring, West Virginia. The in-
vitation was extended by Col. Dan C. Elkin who
is also a member of the Southern Surgical Associa-
tion and Col. C. N. Beck, Commanding Officer of
the Hospital.

Dr. Roland A. Coulson has been appointed in-
structor in the Department of Biochemistry, Lou-
isiana State University School of Medicine. He
holds an M.S. degree from Louisiana State Univer-
sity and a Ph.D. degree from the University of
London. Dr. Coulson has just returned from serv-
ice with the Royal Air Force in Great Britain,
where he did research work for the Division of
Nutrition, Air Ministry.

o

REDUCTION IN THE MEDICAL CORPS OF
THE ARMY

A moderate reduction in numbers of Army Med-
ical Corps officers is necessary in order to remain
within pz-esently allotted ceilings, the Office of
The Surgeon General has announced. The need
for Medical Corps Officers in senior grades who
are assigned principally to administrative duties is
less acute than formerly.

A Board of Officers recently appointed in the
Office of the Surgeon General is carefully con-
sidering the physical and other qualifications of
all Medical Corps officers of the various compo-

Louisiana State Medical Society Neivs

331

nents of the Army and their essentiality to the war
effort.

As a result of this Board’s study, it is antici-
pated that a number of separations of the above
group will occur in the moderately near future.
Regular Medical Corps officers will be accorded
retirement privileges under the provisions of Sec-
tion II, Ar. 605-245, June 17, 1941, and Reserve,
National Guard, and AUS Medical Corps officers
will be given the opportunity of returning to the
practice of medicine in a civilian status by relief
from active duty or discharge.

o

AMERICAN COLLEGE OF SURGEONS

The following doctors from Louisiana have been
accepted into Fellowship of the American College
of Surgeons in 1944:

Drs. Wallace H. Brown, Shreveport; George M.
Haik, New Orleans; William S. Harrell, Jr., Boga-
lusa; Louis F. Knoepp, Shreveport; Henry Leiden-
heimer, Jr., New Orleans; Harry D. Morris, New
Orleans; James S. Newton, New Orleans; Irving
Redler, New Orleans; William F. Thomas, Jr.,
Lafayette; Richard W. Vincent, New Orleans;
John C. Weed, New Orleans..

o

TOURO INFIRMARY

The regular monthly meeting of the medical
staff of Touro Infirmary met on Wednesday, De-
cember 13 at 8:00 p. m. The first order of bus-
iness was a Clinico-Pathological Conference, the
clinical discussion being led by Dr. Alton Ochsner.
Dr. Alan Leslie then spoke on “Physiological As-
pects of Aviation Medicine”, and the program was
completed by a joint paper by Drs. Arthur Caire,
Jr. and B. B. Weinstein who spoke on “Utero-
placental Apoplexy.”

o

CHARITY HOSPITAL

The regular monthly meeting of the Charity
Hospital staff was held on December 19 in the
auditorium of Charity Hospital. The first paper
was presented by Dr. R. C. Lowe on “Hypothy-
roidism.” Dr. E. Phillips then gave a most in-
teresting discussion and case report on “Congen-
ital Cyst of the Lung.” The last part of the pro-
gram was conducted by Dr. H. A. Klein who pre-
sented two patients with intractable gastric ulcer.
The first was a patient who had active pituitary
disease with acromegalic symptoms, and second
was a man who had been operated upon with a
seventy per cent gastrectomy and who again
had a recurrence of the symptoms.

o

INFECTIOUS DISEASES IN LOUISIANA

The morbidity report of the Louisiana State De-
partment of Health showed that for the week end-
ing November 11 there were very few diseases
recorded in numbers greater than 10. These in-
cluded 23 cases of malaria, 20 of pulmonary tu-

berculosis, 18 of diphthei’ia, and 13 each of un-
classified pneumonia and scarlet fever. The un-
usually large number of diphtheria cases reported
was not due to an epidemic. There was not a
single parish in the state reporting more than
two cases. The majority of the malaria cases
came from Jefferson Parish from which 12 were
reported. It might be noted also that there was
one case of poliomyelitis reported this week which
came from Rapides. The morbidity statistics took
a jump in the week ending November 18. There
were listed 43. cases of pulmonary tuberculosis,
35 of mumps, 16 of scarlet fever, 14 of unclassi-
fied pneumonia, 13 of diphtheria, and 12 of mala-
ria. No other reportable diseases were reported in
numbers greater than 10. Eleven of the malaria
cases were reported from military sources. As-
cension, Caddo, and Lafayette each had three
cases of diphtheria. For the last week in Novem-
ber pulmonary tuberculosis again was first in the
number of cases reported with 24 instances, fol-
lowed by 21 of diphtheria, 15 of scarlet fever,
and 14 of malaria. Caddo Parish had five cases
of diphtheria and East Baton Rouge Parish three.
Again the majority of the malaria cases were re-
ported from military sources. Incientally, this
week there were eight cases of typhus fever re-
ported. The week which ended December 2 was
the week when the monthly accumulation of ven-
ereal disease cases is listed. This included 1,073
cases of gonorrhea, 952 of syphilis, 26 of chan-
croid, and 12 of lymphopathia venereum. Other
diseases reported in numbers greater than 10 in-
clude 35 cases of malaria, 30 of influenza, 20
each of pulmonary tuberculosis and diphtheria, 16
of unclassified pneumonia, and 13 of scarlet fever.
In this week the majority of the cases of diph-
theria came from Sabine Parish with eight re-
ported. Most of the cases of malaria were re-
ported from military sources and from Grant Par-
ish. For the first time in many weeks a case of
smallpox was reported, this originating in Red
River Parish.

o —

HEALTH IN NEW ORLEANS

The Bureau of the Census, Department of Com-
merce reported that for the week ending Novem-
ber 18 there were 137 deaths in New Orleans as
contrasted with 156 the previous week. These
deaths were divided 79 white, 58 colored, and 14
of them were children under one year of age,
equally divided between the two races. The next
week which terminated November 25 there was a
slight increase in the number of deaths in the city
due largely to a greater number of white people
dying than the previous week. The figures for
this week were total deaths 143, white 91, non-
white 52, and eight infants under one year of age.
For the week which closed December 2, the 161
deaths in the City of New Orleans were divided
104 white, 57 colored, and 11 infants. For the

332

Book Revieivs

week of December 9 the number of deaths was
approximately the same as in the previous week,
there being an increase of 4. The actual number
of deaths in the white population was the same as
in the previous week, but there were 61 deaths
in the negro population, and of the total number
of deaths 11 of them were in children under one
year of age.

KILLED IN SERVICE
Dr. Wilbur L. Edgerton
(1913-1944)

The State Society has been advised by Mrs.
Edgerton that her husband, Dr. Wilbur Leroy

Edgerton, has been killed in India while serving
as a flight surgeon in the United States Air Corps.
His death took place on September 17, 1944.

Dr. Edgerton graduated from the Louisiana
State University Medical School in 1939 and went
to Simmesport to practice. He was active in the
parish society and was secretary of the organiza-
tion prior to entering military service, and had
been a member of the State Society since his
graduation.

o

BOOK REVIEWS

Neurology of the Eye, Ear, Nose, and Throat : By
E. A. Spiegel, M. D. and I. Somner, M. D. New
York, Grune and Stratton, lllus., pp. 667. Price
$7.50.

“Neurology of the Eye, Ear, Nose and Throat”
stresses the necessity of unification and of a sur-
vey permitting the practitioner and research work-
er to become acquainted with the present state of
knowledge in these allied fields.

Originating in postgraduate lectures held within
the past twenty-five years in Vienna and the
United States the volume is the answer to requests
for a summary in book form.

Anatomy, physiology and pathologic disturb-
ances of the nervous mechanisms related to the
eye, ear, nose and throat are described in vast
and minute detail. Methods of examination of the
functional activity of the higher sense organs, and
of differential diagnosis and treatment of disor-
ders of their innervation, are thoroughly surveyed
and evaluated.

A “restricted” bibliography of 1719 carefully
selected references concludes this amazingly com-
plete, detailed and outstanding contribution to the
complex field of neurology.

C. P. May, M. D.

Manual of Military Neuropsychiatry: Edited by

Harry Ceasar, and P. I. Yakovlev. Philadelphia,

W. B. Saunders Co., 1944. Ulus., pp. 764.

Price $6.00.

The present “Manual of Military Neuropsychia-
try” is a reference text on topics of neurology and
psychiatry prepared especially for medical officers
in service remote from libraries and other sources
of readily accessible neuropsychiatric information,
As far as I have observed little, if anything, for
the good of either the civilian or military doctor
has been omitted.

No two books, by different authors, can ever be
really quite alike and impressed as I am by this

one it is very likely to become a medical classic;
Never have I worked harder and profited as much
from a book as I have while preparing this book
review.

Certain topics are presented in so perfect a
manner and so practically and clearly that I sin-
gle them out for special mention. They are:
16. Phychopathic Personalities; 21. Feebleminded
and Defective Delinquents of Draft Age; 21. Epi-
lepsy and Paroxysmal Neui’opsychiatric- Syn-
dromes; 23 Principal Psychoses; 31. Post Trau-
matic Syndromes; 43. Neuropsychiatric Disorders
in the Tropics. But many of the forty-nine topics
presented are just as fine.

Your reviewer unqualifiedly recommends this
compact volume as an indispensible guide. Be-
tween its covers is contained an extraordinarily
lucid and thorough summary of neuropsychiatric
problems and procedures by specialists eminently
qualified to evaluate them.

Such an important book as this one deserves a
prominent and handy place in the library of every
medically minded person who expects to exert
maximum efforts in alleviating the effects or
nervous and mental illness.

C. P. May, M. D.

Collected Papers of the Mayo Clinic and the Mayo
Foundation, Vof. 34: Philadelphia, W. B. Saun-
ders Co., 1943. Ulus. pp. 999. Price $11.50.

As usual this is a most interesting and informa-
tive volume. There is hardly a section that is
not replete with modern up-to-date medical data
pretaining to diagnosis and treatment. Space will
not permit of any detailed criticism of the book.
It can be stated simply that the book in no way
has suffered because of the war. It is a worthy
successor of its anti-bellum fellows.

I. L. Robbins, M. D.

Book Reviews

333

Synopsis of Diseases of the Heart and Arteries:
By George R. Herrmann, M. S., M. D., Ph. D.,
F. A. C. P. 3rd ed. St. Louis, The C. V. Mosby
Company, 1944. Pp. 516, illus. Price $5.00.

Dr. Herrmann has introduced in the third edition
of this well recognized synopsis on cardiac and
arterial disease much new data as well as con-
siderabe revision of the older material. Notable
is the accentuation of emphasis on cardiac prob-
lems related to wartime medicine. The revision
of chapters and the introduction of broader dis-
cussions on nervous disorders with cardiac mani-
festations, changes in blood pressure, and the gen-
eral systemic types of heart disease, have added
greatly to the usefulness of the volume. Synopses
are not intended to cover the many details of a
subject, and have their advantage in the presen-
tation of the fundamentals. The straighforward
adherence of Dr. Herrmann to this principle in
this synopsis makes the volume a most excellent
source for a quick clear-cut grasp of the many
sided aspects of cardiovascular disease.

W. A. Sodeman, M. D.

Functional Disorders of the Foot; Their Diagnosis
and Treatment: By Frank C. Dickson, M. D.,
F. A. C. S. and Rex L. Diveley. Philadelphia,
Lippincott & Co. 2nd edition, 1944, 352 pages,
202 illustrations. Price $5.00.

The second edition of this book has been in-
creased in size with the addition of several chap-
ters which are of importaance, especially at this
time. One of these, The Disorders of the Foot in
Relation to Military Service, is a concise and com-
prehensive discussion of conditions peculiar to foot
conditions seen in the military services. Some of
the chapters are a condensation of information
found elsewhere in the book. It should prove of
value to anyone treating or interested in condi-
tions of the feet as seen in Military Services from
Induction to the Rehabilitation Center. Another
new chapter which is of especial interest to most
of us is Disorders of the Foot in Relation to In-
dustry which emphasizes the importance of a com-
plete health program for moderate size plants as
well as for the larger industries. It has many
practical points regarding proper foot wear and
foot health.

The second edition offers a little more in the
way of surgical procedures than the first edition
did. As a whole, it furnishes a basic approach
to foot disorders and gives practical time-tested
solutions to commonly encountered foot condi-
tions. This book is not encyclopedic in scope, but
presents the material in a straightforward, simple
manner which is easily comprehended. It should
take its place along with the first edition, pub-
lished in 1939, on the shelves of the working li-
brary of most physicians

Jack K. Wickstrom, M. D.

Vascular Responses in the Extremities of Man: By

David I. Abramson, M. D., F. A. C. P. Chicago,

Univ. of Chicago Pr., 1944. Pp. 412. Price $5.00.

The ambitious undertaking which Dr. Abram-
son’s monograph represents is indicated by its title,
“Vascular Responses in the Extremities of Man in
Health and Disease.” This volume of 387 pages
is arranged in seven parts to include discussions
of the anatomy, physiology and nervous control
of the vessels, the qualitative and quantitative
procedures employed in the study of vessels and
the rate of peripheral blood flow, the vascular
responses to various physical and chemical stimuli,
the blood flow in abnormal states and in systemic
disease, the vascular response in peripheral vascu-
lar disease and, finally, the evaluation of methods
employed in the treatment of these conditions.

The great scope of this presentation coupled
with the small size of the volume have necessarily
resulted in condensed and frequently inadequate
discussions of important subjects. Only two and
one-quarter pages, for instance, are devoted to
the discussion of the physical signs and symptoms
in the study of the vessels and the rate of peri-
pheral blood flow. Bibliographic reference at the
end of each chapter, however, are furnished for
any reader desiring to pursue further the subjects
discussed. The reviewer was disappointed to note
that the author recommended peripheral nerve
blocks as a procedure for the removal of vaso-
constrictor tonus in the study of vessels in prefer-
ence to the more direct and, despite the author’s
statement to the contrary, equally simple proce-
dure of sympathetic ganglion procaine block. The
sections devoted to the vascular responses in vari-
ous functional and organic disease of the vessels
are brief in many instances due to the paucity of
the information on the underlying abnormal phy-
siology in many of these conditions. The authors
whom Dr. Abramson has elected to quote in cer-
tain instances are not the originators of the ideas
expressed. An example which comes to mind is
the reference to a publication appearing in 1930
which pointed out the increased surface tempera-
ture occurring in arteriovenous aneurysms. This
phenomenon was recorded and well understood
by Franz, Matas, and others many years ago. In
the index of this volume, it is noted that cross
references are frequently inadequate, an example
being the absence of any reference under ulcers
to the separate entry of post-phlebitic ulcers, or
likewise the omission of the term aneurysm but
the inclusion of the entry arteriovenous aneurysms.
It is believed that many more illustrations should
have been included for the purpose of presenting
more clearly the technical equipment considered.
Moreover, numerous color plates to illustrate the
clinical conditions under consideration and draw-
ings to present diagramatically the pathologic
physiology of each would have added materially to
the value and clarity of this volume.

334

Book Reviews

Despite the above criticisms, it is the reviewer’s
opinion that Dr. Abramson’s monograph represents
a valuable contribution to the literature of the
subject, since it collects and presents succinctly
the important methods and equipment employed in
the study of conditions producing disturbances in
peripheral blood flow and the evaluation and in-
terpretation of the findings made with these
methods and equipment.

In the foreword, Dr. Abramson has stated that
his book will have accomplished the purpose for
which he intended it “if it serves to inform the
reader of the scope and rapid development of the
field of normal and abnormal peripheral vascular
responses in man.” It is the leviewer’s opinion
that this volume very definitely accomplishes this
purpose.

Major R. G. Holcombe, Jr., M.C., U.S.A.

A Method of Anatomy: Descriptive and Deductive:
By J. C. Boileau Grant, M. C., M. B., Ch. B.
Third edition. Baltimore, The Williams and
Wilkins Company, 1944. Pp. xxiv + 822, figs.
729. Price $6.00.

Commenting in this Journal on the first edition
of Grant’s book (1937), the present reviewer char-
acterized A Method of Anatomy as follows: “An

innovation in the field of anatomical text-books.
Less than a third of the bulk of the familiar texts
of gross anatomy, with original simplified illus-
trations and above all differing- in the method of
presenting subject matter, ‘A Method of Anatomy’
challenges the traditionally plethoric teaching of
anatomical rote . . . Emphasis is given to develop-
ment, physiological and practical considerations,
and the reader is constantly reminded of signifi-
cant deductions to be drawn from observed struc-
ture.” This third edition, like the first, was
planned by the author to provide “a working in-
strument designed to make anatomy rational, in-
teresting and of direct application to the prob-
lems of medicine and surgery.” It can fulfill that
aim even better, with improvements in text matter
and illustrations suggested by an experience of
several years.

Harold Cummins, Ph.D.

Artificial Pneumothorax in Pulmonary Tuberculo-
sis: By T. N. Rafferty, M. D. New York, Grune
and Stratton, 1944. Pp. 192. Price $4.00.

This book is the result of the author’s effort to
bring order out of a great deal of the indecision
surrounding the indications and contraindications
for artificial pneumothorax. He first considers in

a general way the present status of collapse ther-
apy. This is followed by a consideration of the
choice of cases and finally the management is
considered at rather great length. The place of
artificial pneumothorax in its relationship to the
broader aspects of collapse therapy is discussed
and the possibilities and complications of collapse
therapy and especially pneumothorax are well pre-
sented by the author. The book should prove of
value to those interested in this extremely im-
portant phase of phthisotherapy.

I. L. Robbins, M. D.

Manual of Urology: By R. M. Le Comte, M. D.,

F. A. C. S. Baltimore & Wilkins Co., 1944.

Pp. 305. Price $4.00.

Dr. R. M. Le Comte has written here an excel-
lent textbook that wastes no words and also does
not confuse the reader with the various aspects
and diversified opinions on the different urological
subjects. It should be of great value to medical
students and practitioners who desire a book for
their own library which is “to the point.” Of out-
standing value is his common sense treatment
sections. Of course, penicillin as a therapeutic-
measure is not included yet. Dr. Albright’s vari-
ous solutions in treatment of stones are also not
included, perhaps rightly so, because of their still
experimental usage. Dr. Le Comte’s sections on
“Impotence and Sterility in the Male” is particu-
larly good. From the ample bibliography, one can,
if interested, go into greater details on any subject
he desires. As a whole, it is to be quite highly
recommended.

David T. H. Schneider, M. D.

PUBLICATIONS RECEIVED

The Williams and Wilkins Company, Baltimore:
The Woman Asks the Doctor, by Emil Novak,
M. D., F. A. C. S.

The Blakiston Company, Philadelphia: Stitt’s
Diagnosis, Prevention and Treatment of Tropical
Diseases, by Richard P. Strong, M. D., Sc.D., D. S.
M., C. B., seventh edition, Volumes I and II.

Comstock Publishing Company, Ithaca, New
York: Intracranial Arterial Aneurysms, by Walter
E. Dandy. The Mosquitoes of North America, by
Robert Matheson.

Charles C. Thomas, Publisher, Springfield, Illi-
nois: Endocrinology of Woman, by E. C. Hamblen,
B. S., M. D„ F. A. C. S.

The Commonwealth Fund, New York: Atlas of
the Blood in Children, by Kenneth D. Blackfan,
M. D. and Louis K. Diamond, M. D.

New Orleans Medical

and

Surgical Journal

Vol. 97 FEBRUARY, 1945 No. 8

SYPHILIS

THE GREAT MASQUERADER*

JOHN A. KOLMER, M. D.f
Philadelpia, Pa.

While, for several hundreds of years,
syphilis has been known as one of the most
dangerous of the infectious diseases of
human beings, yet the cause was not dis-
covered until 1905, or about forty years ago,
by Schaudinn, who found that it was due
to a microorganism now known as Trepon-
ema pallidum or Spirochaeta pallida. About
a year later Wassermann and his colleagues
discovered a blood test for the disease
which, after undergoing improvements and
modifications in technic, is now universally
employed as an extremely valuable aid in its
detection and treatment. At about the same
time it was found that syphilis could be
transmitted to monkeys and rabbits which
immediately opened up a field for chemo-
therapeutic investigations culminating, in
1910, in the brilliant discovery of salvarsan
by Ehrlich, Bertheim and Hata. Thus in a
space of only five years there was discover-
ed the cause of one of the most important
diseases of mankind, a blood test of unsur-
passed diagnostic value in its detection, and
a sovereign specific remedy for its treat-
ment, constituting a triad of triumphs un-
paralleled in the history of medicine.

* Stanford E. Chaille Memorial Oration delivered
before the Orleans Parish Medical Society, Novem-
ber 6, 1944.

f Professor of Medicine, Temple University; Di-
rector of the Research Institute of Cutaneous
Medicine, Philadelphia.

INCIDENCE OF SYPHILIS

Syphilis is world-wide in distribution
since all human races and both sexes of all
ages are susceptible to it. The true inci-
dence of the disease in the United States is
unknown. Suffice it to state that it varies
greatly in different localities and among
different social groups from as low as 0.2
to 0.5 per cent to as high as 20 to 30 per
cent. This incidence is higher among ne-
groes than among whites and higher in
cities than in urban communities. Esti-
mates of the incidence have been based upon
the results of blood tests but since the true
incidence is always higher than that reveal-
ed by these examinations, the average for
the whole country has been estimated to be
as high as 8 to 10 per cent of the population.
If this is true, more than 10,000,000 indi-
viduals in the United States have syphilis,
most of whom either do not know they have
the disease or regard themselves as having
recovered from it.

It is believed that about 91 per cent of in-
dividuals contract syphilis between 16 and
40 years of age, with an estimated 500,000
to 600,000 new cases per year during nor-
mal times. Every person with acquired
syphilis is considered potentially respon-
sible for the infection of at least one to
three or more additional individuals. In-
deed, it has been estimated that about 1,-
000,000 of the potential mothers of this
country have syphilis, and among syphilitic
mothers only about 17 per cent of pregnan-
cies result in the birth of living, non-syphili-
tic children. The remaining 83 per cent re-
sult in miscarriages, stillbirths, or living
children with the disease. This means that
each year about 25,000 infants are killed by

336

Kolmer-

■Syphilis

syphilis before birth while about 60,000 are
born alive with it. All of this could be pre-
vented and congenital syphilis wiped out if
all women would seek medical care before
the fifth month of pregnancy, if every
physician would include a blood test rou-
tinely in his examination, and if every preg-
nant syphilitic woman were to receive
prompt and adequate treatment. Practicing
physicians frequently hesitate or refuse to
have the blood tests conducted because of
fear of offending the patient, but respecta-
bility and social position are no bars to in-
fection with Treponema pallidum. Further-
more, since various blood examinations are
conducted for the diagnosis of the anemias,
diabetes mellitus, or Bright’s disease, it is
always possible for the physician to take a
little extra blood for the syphilis tests with-
out necessarily informing the patient. For-
tunately, in hospitals, it is now a wide-
spread routine custom to conduct the tests
in all ward patients, with the result that
many cases of the disease are discovered
which otherwise would escape detection. Let
it be fervently hoped that the same will be
progressively true of all patients in private
rooms and in private practice because syph-
ilis strikes the high as well as the low and
because an honest denial of all knowledge
of having contracted the disease by no
means excludes its possible presence.

In this connection it is also to be stated
that since the Red Cross conducts blood
tests for syphilis in all donors of blood for
the preparation of plasma for use in our
armed forces, a very large number of un-
suspected cases of the disease have been de-
tected. This constitutes a blessing in dis-
guise for the individuals involved from the
standpoint of treatment, although, as will
be discussed later, the injection of plasma
prepared of the blood of a syphilitic person
carries no risks of transmission of the in-
fection since Treponema pallidum is killed
during the process of preparation and stor-
age of the plasma in the dried state.

Premarital Blood Tests: Under the condi-
tions I am thoroughly in favor of laws re-
quiring blood tests for syphilis before mar-
riage for the following reasons: (1) be-

cause the disease inevitably involves syph-
ilitic men and women, in view of its high in-
cidence; (2) because the detection and ade-
quate treatment of syphilis before marriage
will reduce its incidence; (3) because the
tests are the most valuable single means for
the detection of the disease after the pri-
mary or chancre stage; (4) because of the
inadequacy of a negative history and clini-
cal detection in applicants for licenses; (5)
because the tests will help reduce the inci-
dence of infection of marital partners and
children by detecting the disease before
marriage; (6) because the tests will reduce
the economic hazards of marriage from in-
capacity to work or premature death of the
husband or wife because of syphilis; (7)
because the tests will reduce the incidence
of divorce; (8) because the tests will great-
ly encourage the thorough treatment of
syphilis and (9) because the tests are an
excellent phase of the educational campaign
against the disease.

Blood Tests During Pregnancy : For the
following reasons I am also in favor of laws
requiring blood tests during pregnancy:
(1) they afford an excellent opportunity for
detecting syphilis in both married and un-
married mothers, especially since preg-
nancy alone does not give falsely positive
reactions when the tests are properly con-
ducted; (2) because the detection and treat-
ment of syphilis in pregnancy increases the
chances of the birth of a healthy child with
a reduction in the incidence of miscarriage
and of infant mortality; (3) the detection
of syphilis in pregnancy results in the treat-
ment of the mother and especially during
subsequent pregnancies; (4) the detection
of syphilis in pregnancy may result in its
detection and treatment in the child after
birth and (5) the detection of syphilis in
pregnancy may lead to its detection and
treatment in the father and in other chil-
dren.

TRANSMISSION OF SYPHILIS

In about 90 to 95 per cent of cases syph-
ilis is acquired by sexual contact and for
this reason is included among the venereal
diseases. Most of the balance of cases are
acquired extragenitally, especially on the

Kolmer — Syphilis

337

lips by kissing, on the fingers or other parts
of the body. Since the germ, Treponema
pallidum, dies quickly upon removal from
the body, it is estimated that probably not
more than one in ten thousand cases con-
tract the disease from toilet seats, clothing,
and so on. However, the immediate use of
eating and drinking utensils, pipes, cigar-
ette holders, after contamination by the
saliva of syphilitic individuals with acute
lesions on the lips or in the mouth, is far
more dangerous.

Fortunately, not all persons sexually ex-
posed to the disease contract it ; about 10
per cent escape, not because they have a
natural immunity to syphilis, but because
of the removal or destruction of Treponema
pallidum by prompt washing of the geni-
talia, douching, or the use of contraceptive
jellies. Indeed prompt and thorough wash-
ing of the parts with hot water and soap,
followed by the thorough application of a
33 per cent ointment of calomel, has proved
highly successful in the prophylaxis of
syphilis, especially in the case of men, al-
though but seldom used by the laity in civil-
ian life.

Syphilis may be transmitted during the
incubation period of two or three weeks or
more following exposure and infection be-
fore the development of a chancre at the
site of inoculation. But the disease is most
contagious during the primary or chancre
stage and the secondary stage of the dis-
ease characterized by eruptions of the skin
and mucous membranes, with special refer-
ence to the mouth ; also during later periods
when relapses of the disease result in active
or open mucocutaneous lesions. In most in-
stances the disease is contracted by expo-
sure to syphilitic individuals infected with-
in a period of two years. In the case of an
individual with syphilis of five years’ dura-
tion, the chances of transmission to others
are about one in 20 or less and after ten
years, one in 100 or less, although it is not
possible to ignore the risks of infection in
later years of the disease. The semen may
be infectious during the first four years of
the disease but rarely so thereafter, regard-
less of whether or not treatment has been

given. It is thought possible, however, for
an untreated syphilitic mother to transmit
Treponema pallidum to a nursing infant by
way of her milk during the first four or
five years of the disease; under these condi-
tions it is safer for her not to nurse her
child.

Syphilis is also sometimes transmitted by
blood transfusions. This accident is always
most likely to occur if the untreated donor
is in the early stages of the disease but may
happen if he or she has had the disease as
long as five to seven years. Otherwise there
is but little or no danger but it is always
advisable to exclude all syphilitic donors. In
case of necessity, however, a syhilitic donor
may be safely used providing neoarsphena-
mine or mapharsen is added to the citrated
blood at least fifteen minutes before trans-
fusion for the purpose of killing any spiro-
chetes that may be present. Since Trepon-
ema pallidum is killed during the prepara-
tion and storage of plasma in a dried state,
its injection carries no risks of infection.
The same is true in the case of stored ci-
trated blood providing it is at least three to
five days old, since it has been shown that
Treponema pallidum dies off in this period
of time.

As previously stated, the danger of trans-
mission of syphilis is always greatest dur-
ing the early stages of the disease, embrac-
ing a period up to six months or a year fol-
lowing its contraction. Fortunately, how-
ever, adequate treatment, especially with
arsphenamine, neoarsphenamine or maphar-
sen, quickly kills surface spirochetes and
greatly reduces the chances of transmis-
sion. For this reason the prompt diagnosis
and adequate treatment of the disease in
the early stages places a heavy responsi-
bility on physicians, not only in relation to
the patient, but in relation to the protection
of others exposed to the risks of infection.
The same is true in the case of the muco-
cutaneous relapses of the disease, 95 per
cent of which occur in the first three years
of the disease. These dangerous relapses, as
well as treatment-resistant cases of syph-
ilis, are not due as much to the failure of
the organic arsenical and bismuth com-

338

Kolmer — Syphilis

pounds in treatment as to the fact that the
individual fails to develop an immunity to
Treponema pallidum.

Up to this point my remarks have been
confined to the transmission of syphilis
among adults and do not apply to transmis-
sion to the infant in utero during preg-
nancy which constitutes congenital syph-
ilis. Strictly speaking, the latter is acquired
syphilis since it is syphilis acqured by the
child through the placental transmission of
T reponema pallidum. If a woman contracts
syphilis during the last four to six weeks
of pregnancy the child may escape infection
in utero, but if she has a chancre or other
early lesion in the birth canal the child may
become infected during birth and develop
what is known as infantile syphilis.

Formerly it was believed that a syphilitic
father could transmit the disease to his
child in utero without infecting the mother.
This so-called paternal transmission of the
disease, however, is no longer accepted.
Rather it has been amply proved that syph-
ilis is transmitted in utero only through the
mother. For this reason it is a safe assump-
tion that all mothers of syphilitic children
have the disease regardless of the fact that
they may show no clinical evidences of it
and give negative serologic reactions.

Untreated pregnant syphilitic women are
especially likely to transmit syphilis to their
infants in utero during the first year of the
disease. But the risk is not entirely removed
by the passage of time and may be stated
to be present during the whole of the child-
bearing age. Fortunately, however, syph-
iltic women may bear healthy non-syphilitic
children and especially after the first year
or two of the disease. This depends upon
whether or not Treponema pallidum gains
access to her blood during pregnancy with
placental transmission of the germ to the
child. As previously stated, adequate treat-
ment during pregnancy guarantees the
birth of a healthy non-syphilitic child al-
most as surely as vaccination prevents
smallpox. In this connection it may be
stated that syphilitic mothers should be
treated throughout every pregnancy, re-
gardless of the type or duration of her own

infection or of the amount of preceding
treatment. Furthermore, the treatment
should be started as early as possible in
every pregnancy.

CLINICAL STAGES OE SYPHILIS

Acquired Syphilis: Following infection
with Treponema pallidum the parasite rap-
idly invades the lymphatics and the blood,
but a sore does not appear at the site of in-
oculation until 10 to 90 days later (average,
21 days), which is called the incubation pe-
riod. The painless, indurated, raised and
eroded lesion is the chancre and this, along
with some enlargement of the neighboring
lymph nodes, constitutes the primary stage
of the disease. However, the sore may be so
small that it escapes detection or it may be
regarded as only a hair cut, an innocent
pimple or a simple blister. Or it may be sit-
uated in the urethra and produce a dis-
charge which may be regarded as due to
gonorrhea. At all events it is particularly
likely to escape the notice of women. Not
infrequently the victim makes his or her
own diagnosis and goes to the drug store
for a dusting powder for self medication.
All of this may result in disaster. On the
contrary, if the diagnosis of syphilis is
made at that time with the institution of
prompt and adequate treatment, the chances
of complete recovery from the disease are
at least 90 to 95 per cent.

Unfortunately, however, physicians
themselves are frequently responsible for
mistakes in diagnosis. Far too many depend
upon their clinical judgment alone and for-
get that the primary sore on the genitalia
can masquerade under a variety of condi-
tions including chancroid and herpes geni-
talis. Under the conditions and always when
in doubt, a darkfield microscopic test for
Treponema pallidum should be made. In
other words, it has been aptly and truth-
fully stated that the diagnosis of primary
syphilis is no longer a clinical but a labora-
tory problem. But since it takes time for
the antibody or reagin to be produced a
blood test is never likely to give a positive
reaction until the sore is present for at
least 10 to 15 days. Under the conditions a
single negative serologic reaction is a very

Kolmer — Syphilis

339

frequent cause for missing the diagnosis of
syphilis in the primary stage although after
two weeks, when the sore is healing and a
darkfield examination may be difficult or
impossible, positive reactions may be ex-
pected in about 70 to 80 per cent of cases.

Unfortunately there are even greater
chances of missing the diagnosis if chancres
occur on the lips, fingers or other parts of
the body since they may not excite suspi-
cion. Altogether too frequently a chancre on
the lip is regarded as nothing more than a
“cold sore” while one on the fingers is fre-
quently mistaken for a streptococcus or
staphylococcus infection. Under the circum-
stances chancres on the lips may be the
means of transmitting the disease to others,
especially by kissing, before the true diag-
nosis is made. Consequently, physicians and
the laity as well should never ignore a per-
sistent sore on the lips or fingers as there
is always a chance that it may be syphilitic.

Under the conditions it is no wonder that
about 30 per cent of men and 60 per cent of
women, found in later years to have chronic
syphilis, are perfectly honest and sincere
in denying all knowledge of having con-
tracted the disease. A negative history
therefore is of little or no value in excluding
its possible presence. Furthermore, and
most unfortunately, such cases of primary
syphilis may unwittingly spread the disease
to others and become a public health menace
conceivably greater than patients with
frank and typical chancres.

At all events in untreated cases the
chancre slowly heals in four to six weeks,
frequently without leaving a scar. This is
followed by a period of four to eight weeks
during which the patient may be without
symptoms or the disease masquerade un-
der such general manifestations as malaise,
chilliness, anemia, bodily aches and pains,
headache and general enlargement of the
lymph nodes. Fortunately, however, the
blood tests yield positive reactions in about
80 to 85 per cent of cases and therefore con-
stitute at this time a valuable means for the
diagnosis of the disease which otherwise
may escape detection.

At the end of this period syphilis reaches
its secondary stage characterized by various
skin eruptions and “mucous patches” in the
mouth, on the prepuce or about the vagina
or occur as condylomata in the axilla, per-
ineum and female genitalia. As in primary
syphilis, these lesions are highly infectious,
but they may be so light and evanescent
that they go unnoticed. Furthermore, they
are not always easy of clinical diagnosis and
at that time the great masquerader may
resemble many different diseases of the
skin. Fortunately, however, the blood tests
give positive reactions in almost 100 per
cent of cases.

The patient then enters a period of in-
determinate length, varying from a few
months to a lifetime, but averaging about
seven years, during which there are no out-
ward signs or symptoms of syphilitic infec-
tion, and the presence of the disease is de-
tectable, if at all, only by means of blood
and spinal fluid tests. This is the so-called
latent stage and involves a large number of
individuals unknowingly infected with
syphilis and those who believe that they
have recovered from it. In other words, the
disease now masquerades under the disguise
of good health which is the most treacher-
ous of all. Blood and spinal fluid tests, how-
ever, yield positive reactions in over 90 per
cent of untreated cases and are, therefore,
of inestimable value in diagnosis. In the
absence of ill health one may question
whether or not treatment is necessary or
advisable but I am among those who believe
that if the patient is less than 60 years of
age, it should be given with the hope and
reasonable expectation of preventing furth-
er progression of the disease and its pos-
sible transmission to others.

In other words, the term “latent stage”
is frequently a misnomer because in the ab-
sence of adequate treatment syphilis is not
usually truly latent. Rather it is in a stage
in which Treponema pallidum is slowly and
progressively producing chronic inflam-
matory changes in the internal organs in
spite of the absence of signs and symptoms
of illness; under the conditions one could
more properly speak of it as the “stage of

340

Kolmer — Syphilis

concealment.” But sooner or later these in-
flammatory changes give rise to the signs
and symptoms of the tertiary stage which
is characterized by the explosive, destruc-
tive effects of gummata or by the break-
down of important tissues, especially in the
cardiovascular or central nervous systems,
resulting from the effects of chronic peri-
vascular inflammation and fibrosis. Indeed,
the disease may now affect practically any
organ or tissue of the body — hence, tertiary
syphilis is a disease encountered in every
specialty in the practice of medicine and
surgery. Furthermore, its manifestations
may be so many and diverse as easily to
escape clinical diagnosis. In other words the
great masquerader may now resemble so
many diseases of the heart, blood vessels,
liver, stomach, brain, spinal cord, skin,
bones, joints, eyes, ears, nose or throat,
that the great Osier is reputed to have
stated that to know syphilis in all of its
manifestations is to know clinical medicine.
Under the circumstances no one can even
estimate the frequency with which physi-
cians fail to detect the disease at this time.
These signs of commission in diagnosis,
however, would be greatly reduced if the
blood and spinal fluid tests for syphilis
were conducted more routinely, especially
in private practice, since positive reactions
occur in the great majority of cases of syph-
ilis in this stage of the disease.

Congenital Syphilis: Frank clinical mani-
festations of early congenital syphilis at
birth are rare at present, since so many
syphilitic women receive some treatment
during pregnancy. As a result, those
children who are born alive are apparently
normal at birth. It is extremely important,
however, to determine the presence or ab-
sence of syphilis in infants as promptly as
possible. For this purpose a darkfield ex-
amination of scrapings from the wall of
the umbilical vein for Treponema pallidum,
if positive, establishes diagnosis within a
few hours after birth, but negative results
do not exclude the disease. A positive blood
reaction at birth or any time within two
weeks thereafter does not necessarily mean
that the child has syphilis, as it may be

due to antibody or reagin passively trans-
ferred from the maternal blood through the
placenta. But if positive reactions are con-
sistently observed at intervals up to six or
eight weeks, syphilis is present. If con-
sistently negative over that period and at
subsequent intervals of six months, one year
and two years, it may be safely assumed
that the child has escaped the disease.

Further aid in early diagnosis may be
furnished by x-ray examinatins of the long
bones two weeks after birth, but only if the
mother has received no bismuth during
pregnancy, as that compound may produce
changes which are hard to differentiate
from syphilitic osteochondritis. If diagno-
sis has not been established and treatment
not instituted, clinical manifestations tend
to appear within the first two or three
months, if at all. These take the form of
snuffles, skin lesions, osteitis and perios-
titis.

The clinical manifestations of late con-
genital syphilis, however, are so many and
diverse that the great masquerader fre-
quently taxes the utmost diagnostic skill of
the physician. These include not only the
so-called stigmata like the “saddle” nose,
“dish-shaped” face, “sabre” shins, Hutchin-
son’s teeth, corneal scars, and nerve deaf-
ness, but progressive active lesions as well.
But few infants and children with congeni-
tal syphilis, however, will present such ob-
vious manifestations that medical care is
sought. Furthermore, a falsely negative
blood reaction may occur, although positive
reactions are observed in the majority.
Otherwise unrecognized and unsuspected
congenital syphilis is frequently discovered
by the routine examination of the entire
family of a parent who has the disease. The
necessity for this becomes particularly im-
portant when the mother is found to have
syphilis, or when another child is found to
have congenital syphilis.

IMMUNITY IX SYPHILIS

As previously stated, natural immunity
to syphilis probably does not exist among
human beings. Numerous instances re-
corded in the literature purporting to know

Kolmer — Syphilis

341

the existence of individual immunity are
explainable on the basis of accidental for-
tuitous escape from infection due to the
intact epithelial barriers of the skin and
mucous membranes. Races, however, vary
somewhat in susceptibility to the disease
and among those people in whom it is first
introduced, syphilis is frequently more vir-
ulent than usual.

But immunity is undoubtedly acquired
during an attack of the disease and has an
extremely important influence upon the
course of the infection and the subsequent
fate of the individual. It begins to develop
upon the appearance of the chancre and
progressively increases during the secon-
dary stage. It is undoubtedly responsible
for the latent stage of syphilis, following
which it begins to fluctuate and to diminish.
Treatment just sufficient to heal the chan-
cre and secondary lesions but insufficient
to effect a complete cure is, therefore, more
likely to be harmful and dangerous than no
treatment at all because it reduces the de-
gree of acquired immunity. Consequently,
once the treatment of early syphilis is
started it must be thorough in order to ef-
fect a complete cure. This places a heavy
responsibility upon the physician and
should be always carefully explained to the
patient. Otherwise the inadequate treat-
ment of syphilis during the first four years,
especially during the first year, favors the
dissemination of Treponema pallidum
throughout the body and may do more harm
than good although inadequate treatment
is much less dangerous after that time. In
other words, the thorough treatment of
early syphilis replaces immunity but is less
essential in chronic syphilis.

The nature and mechanism of this ac-
quired immunity to syphilis is not com-
pletely understood. Undoubtedly it is
largely of the tissue type and in many re-
spects is similar to the acquired immunity
of tuberculosis. It is engendered only by
living Treponema pallidum or an actual at-
tack of the disease and cannot be produced
by active immunization with vaccines pre-
pared of the killed spirochetes. Conse-
quently there is no method for vaccination

against syphilis. Nor can the immunity be
produced by an attack of yaws, relapsing
fever, malaria or any other disease. Small
amounts of specific antispirochetal anti-
bodies also occur in the blood and doubtless
play some part in the mechanism of this ac-
quired immunity. But these antibodies
have so little curative properties that there
is no effective method for the treatment of
syphilis with convalescent human serum or
the sera, of horses or other animals immu-
nized by injections of Treponema pallidum.
Apparently women develop this immunity
in higher degree than men; the reason is
unknown but it may be due to the influence
of the female sex hormones.

The important question arises of whether
or not this acquired immunity is sufficient
for bringing about complete recovery from
syphilis unaided by specific treatment. It
has been stated that about 25 per cent of
cases of the disease may undergo sponta-
neous recovery due to the immunity alone
but the evidence is not conclusive. In my
opinion it is both unwise and dangerous for
any individual with syphilis to assume that
recovery will follow by maintaining good
health through exercise and diet alone un-
aided by adequate treatment. Indeed, the
immunity may not suffice for the preven-
tion of super-infection which means that
an individual may contract a second attack
of the disease before completely recovering
from the first, although a chancre may not
develop when the second attack occurs. It
is also stated that re-infection, which
means a second attack of syphilis, indicates
that complete biologic cure of the first at-
tack has been accomplished but this is no
longer thought to be necessarily true. It
may be that the immunity persisting after
complete cure may prevent re-infection or
a new attack of the disease, but this can
never be relied upon and it appears both
wiser and safer for the individual to as-
sume that he or she is again vulnerable to
a second attack.

SEROLOGIC TESTS FOR SYPHILIS

In no other disease have blood or sero-
logic tests been as widely and usefully em-
ployed as aids in diagnosis as in syphilis.

342

Kolmer — Syphilis

The original Wassermann test and many of
its earlier modifications are no longer em-
ployed but, fortunately, its intrinsic merit
enabled it to survive all the abuses com-
mitted in its name. Newer and superior
methods in both complement-fixation and
flocculation procedures have been devel-
oped during the past twenty-two years with
the result that those commonly and widely
employed at the present time have proved
to possess a high degree of sensitivity and
practical specificity when conducted exact-
ly as described by their author-serologists.
Even under the best of conditions errors
can occur but their incidence is to a large
extent in relation to the skill and experi-
ence of those who conduct them. No test
can be better than the laboratory conduct-
ing it. But common sense in their use and
interpretation is essential. They do not
always provide an easy or royal road to
diagnosis; after all, they are usually only
additional diagnostic aids although in
chronic latent syphilis they may be and
frequently are the sole means for detecting
the disease. Final judgment and responsi-
bility in their interpretation is properly the
function of the physician and he should not
attempt to “pass the buck” to the technol-
oligst who is doing his or her full duty
when seeing to it that the tests are con-
ducted exactly as they should be, using
every known precaution against error and
reporting the reactions exactly as observed
and not as the physician expects or desires.

As previously stated, in view of the wide
prevalence of syphilis in both sexes and all
races, the frequency with which it is re-
sponsible for chronic disease when not sus-
pected clinically, and the fact that a nega-
tive history and respectability are unreli-
able in excluding the possibility of its
presence, renders advisable the routine use
of the tests in the majority of patients in
both clinic and private practice. Indeed,
physicians as a whole need to be more
“syphilitic conscious” and to suspect the
possibility of the great “masquerader”
among both the high and the low.

The serologic tests for syphilis should
possess the maximum of sensitivity consis-

tent with specificity. They are divisible
into two kinds, namely: (a) complement-
fixation or Wassermann, and (b) floccula-
tion tests, the latter being subdivided into
macroscopic and microscopic procedures.
The nature of the antibody-like substance
concerned in their mechanism is unknown
but since it does not appear to be a true
antibody it is commonly designated as a
“reagin.” As previously stated, agglutin-
ins and complement-fixing antibodies for
Treponema pallidum are produced in syph-
ilis but appear to be separate and distinct
from the reagin. At least complement-fix-
ation or Wassermann tests conducted with
antigens prepared of cultures of alleged
Treponeum pallidum do not appear to be
of as much practical value as antigens pre-
pared of the lipoids extracted from beef
heart or other mammallian tissues. Fur-
thermore, tests conducted with spirochetal
antigens are far more likely to yield false-
ly positive reactions due to the fact that a
large percentage of normal persons carry
in their blood a nonspecific spirochetal an-
tibody giving group reactions with antigens
prepared of Treponema pallidum and other
spirochetes.

None of the present serologic tests is suf-
ficiently sensitive to detect all cases of
syphilis. Nor can this be reasonably ex-
pected since in both early and late cases
of the disease there may not be sufficient
amounts of the reagin in the blood to give
positive reactions. Consequently, negative
reactions and even repeatedly negative re-
actions should not be permitted to over-ride
clinical judgment. All of the tests now in
use can be made more sensitive but only at
the risk of giving falsely positive reactions.
In my opinion it is far better to miss the
serum diagnosis of occasional cases of
chronic latent syphilis than to incur un-
necessary risks of falsely positive reactions
with all that this may mean to the individ-
uals concerned. But since there is no one
best test for syphilis, I believe that, when
conditions permit, the serum diagnosis of
syphilis is best served by testing each serum
by at least two methods routinely and that
one of them should be a complement-fixa-

Kolmer — Syphilis

343

tion or Wassermann test of acceptable sen-
sitivity and specificity. When one test
gives a positive reaction and the second test
gives a negative reaction the results should
be regarded as doubtful. In other words,
multiple tests may yield discordant reac-
tions and especially if sera or spinal fluids
contain but small amounts of reagin. The
same is true when portions of the same
blood are sent to different laboratories or
to the same laboratory under different
names as “split specimens.” But doubtful
reactions should not be ignored as they fre-
quency indicate the presence of syphilis.
Under the conditions the tests should be
repeated along with thorough clinical ex-
aminations for the purpose of reaching a
final decision.

Unfortunately falsely positive reactions
are of frequent occurrence but are less like-
ly to occur in complement-fixation than in
flocculation tests. They are divisible into
two kinds, namely: (a) technical and (b)
biologic or those occurring with the sera of
normal individuals and in diseases other
than syphilis. Technical falsely positive re-
actions may be due to contamination, im-
proper storage or delay in sending speci-
mens to the laboratory, or the mislabelling
of specimens on the part of the physician
or to errors in the laboratory. Such errors
occount for the majority of falsely positive
reactions. Biologic falsely positive reac-
tions may occcur with the sera of perfectly
normal nonsyphilitic individuals but are
rare. The great majority are the result of
other diseases and especially yaws, pinta,
leprosy, malaria, vaccinia and vaccinoid,
infectious mononucleosis and virus pneu-
monia. Falsely positive reactions may also
occur in some cases of upper respiratory
tract infections, active tuberculosis, septi-
cemia, subacute bacterial endocarditis,
acute lupus erythematosus, relapsing fever,
rat bite fever, infectious jaundice, typhus
fever, trypanosomiasis and possibly in other
diseases as well. Their management in
practice is always a difficult problem. When
suspected, the tests should be repeated with
great care and skill to avoid technical non-
specific reactions. Judgment and treat-

ment should be withheld and the test re-
peated over a period of at least three to six
months. If negative reactions occur, syph-
ilis may usually be excluded ; if positive re-
actions persist, syphilis is probably present,
if malaria and leprosy can be excluded, then
treatment is advisable.

In other words, when the possibility of
falsely positive reactions can be excluded
positive reactions by properly conducted
tests of proved value are almost invariably
indicative of syphilis. Unexpected reac-
tions should always be rechecked before the
patient is informed or treatment instituted
in order to guard against falsely positive
reactions. On the other hand, they should
never be ignored or disregarded as they
may be the only evidence of syphilis. The
value of verification tests is uncertain but
they are worthy of trial. Provocative sero-
logic reactions are sometimes of value in
the diagnosis of untreated syphilis present-
ing suspicious lesions with negative reac-
tions; also in cases presenting no lesions
with weakly positive or doubtful serologic
reactions.

The serologic tests are also of value as
an aid in guiding the treatment of syphilis.
But the treatment of early syphilis should
be thorough and adequate regardless of neg-
ative reactions. After the cessation of
treatment of early syphilis repeatedly nega-
tive reactions over a period of two years
are among the criteria of cure. At least
one examination of the spinal fluid is also
required.

Persistently positive reactions in early
and late syphilis, in spite of thorough treat-
ment, are indicative of persistent infection
giving “Wassermann-fastness” or “treat-
ment resistance.” Needless to state the in-
cidence of such cases is in intimate rela-
tionship to the sensitivity of the tests em-
ployed. In early syphilis they are frequent-
ly due to inadequate treatment with infec-
tion of the cardiovascular or central ner-
vous systems but when they occur in spite
of thorough treatment it would appear that
they are due primarily to the fact that the
patient has failed to develop an effective
degree of immunity, They always present

344

Kolmer — Syphilis

one of the most difficult problems in the
treatment of syphilis because they are so
discouraging to both physician and patient.
Under the circumstances it is advisable
carefully to explain matters to the patient.
Certainly if treatment is given it is prima-
rily for the purpose of preserving good gen-
eral health and longevity rather than for
the mere purpose of securing negative sero-
logic reactions. In other words, it is the
patient rather than his positive reactions
that requires therapeutic management.

It is always advisable to examine the
cerebrospinal fluid at the end of about six
months of treatment in early syphilis and
at once in all cases of late syphilis. These
tests should include a total cell count, a
test for protein, the collodial gold or mastic
tests, and the complement-fixation or a
flocculation test. Negative results do not
necessarily exclude possible infection of the
central nervous system. About 25 per cent
of all untreated cases of syphilis develop
some type of neurosyphilis embracing about
5 per cent paresis, 5 per cent tabes dorsalis
and 15 per cent diffuse meningovascular
syphilis. Even modern intensive treatment
does not eliminate the possibility of 1 to 3
per cent cases of tabes or paresis. The hope
of escaping these dreadful diseases depends
upon early examination of the cerebrospi-
nal fluid and prompt treatment with try-
parsamide with or without fever therapy.
Under the circumstances no case of syphilis
can be regarded as “cured” without at least
one or more thorough examinations of the
cerebrospinal fluid with completely nega-
tive total cell, protein, Wassermann and
collodial gold or mastic. reactions.

( T'KABILITY AX'D PROGNOSIS OF SYPHILIS

Is syphilis curable? Needless to state
the anxious patient is mostly concerned
about his or her chances of becoming and
remaining well with no later trouble from
the disease. The answer depends upon
what is meant by “cure.” Biologic cure
means the complete and total eradication of
the infection and is the ideal objective of
treatment. Serologic cure means that the
blood and spinal fluid reactions have be-
come persistently negative; unfortunately,

however, this is not necessarily synonymous
with biologic cure since the patient may
still harbor foci of infection capable of sub-
sequent progression or relapse with the re-
turn of positive reactions and the need for
further treatment. Symptomatic cure
means that the patient has become and re-
mains well, so far as syphilis is concerned,
for the balance of life with no danger of
transmission of the disease to others. In
other words, the latter means the “clinical
arrest” of the disease even though positive
blood or spinal fluid reactions, or both, per-
sist for the balance of life. Opinions vary
as to whether or not it is advisable or neces-
sary to give periodic courses of treatment
for the maintenance of the state of good
health in the presence of positive blood or
spinal fluid reactions. Personally, I am
convinced that the latter are indicative of
persistent infection and it is my custom to
advise the patient to take two short courses
of treatment per year, each consisting of six
to eight intramuscular injections of bismuth
at weekly intervals, for the purpose and
with the hope and expectation that they
will aid in keeping the infection in a state
of clinical latency.

It is not my purpose to discuss the ther-
apy of syphilis but suffice to state that it
appears reasonably certain that the treat-
ment of primary and secondary syphilis
with the organic arsenical and bismuth
compounds by the continuous method of
the Clinical Cooperative Group, or modifi-
cations of it, over a period of about fifteen
months, results in the biologic cure of at
least 80 to 95 per cent of cases. But is it
possible to achieve these results in a shorter
period of time and with less expense? The
need for this has lead to great interest at
the present time in the massive arsenother-
apy of the disease familarly knowm as the
“five-day,” or “ten-day,” “three w?eeks” and
similar plans of treatment. In my opinion
the “five-day” treatment, consisting of
three or four injections of arsphenamine,
neoarsphenamine or mapharsen per day, is
too dangerous because of the production of
severe and even dangerous toxic reactions
like encephalopathy, hepatitis, exfoliative

Haik — Cataract Surgery

345

dermatitis, neuritis and blood dyscrasias in
about 3 to 4 per cent of cases with an occa-
sional death. As recently reported by
Thomas and Wexlar and the United States
Public Health Service, one intravenous in-
jection of marpharsen per day for ten days
with intravenous injections of typhoid-para-
typhoid vaccine on the second, fourth, sixth
and eight days for the production of fever
is safer, results favorably in about 80 per
cent of cases of early syphilis, but carries
a mortality of about 0.3 per cent. Eagle
has reported that three intravenous injec-
tions of mapharsen alone per week for eight
to twelve weeks gives poor results in the
treatment of early and latent syphilis but
if these are given along with weekly intra-
muscular injections of bismuth subsalicy-
late, much better results are secured,
amounting to the probable biologic cure of
85 to 90 per cent of cases of early syphilis.
In a series of 4,823 cases, however, severe
toxic reactions were observed in 39 with
four deaths. Where short and intensive
treatment is thought advisable, however,
this method would appear to be the safest
and most desirable although, for my own
part, I prefer not to have my patients incur
the risks and for this reason much prefer
the slower and safer continuous treatment
over about fifteen months, according to the
plan of the Clinical Cooperative Group. In-
deed, if a patient with primary or secondary
syphilis insists upon short intensive ther-
apy, I believe that injections of penicillin
over eight days, along with mapharsen, as
described by Mahoney, are likely to be just
as effective and certainly much safer be-
cause of the extremely low toxicity of this
compound, although the final results of pen-
icillin therapy in early syphilis and its value
in the treatment of latent and chronic syph-
ilis cannot be stated in final terms at the
present time.

At all events, it does not appear that com-
plete recovery or the biologic cure of syph-
ilis is possible when treatment is instituted
two years or longer after the disease has
been contracted. But thorough treatment
with the organic arsenicals and bismuth
compounds or, possibly, with penicilin is

always promising and very hopeful from
the standpoint of effecting symptomatic
cure with the maintenance of good general
health for the balance of the usual span of
life. Even in active tertiary syphilis with
disease of the brain, spinal cord, cardio-
vascular and other organs and tissues, care-
ful, judicious and thorough treatment is
usually effective in ameliorating the signs
and symptoms or reducing the progress of
the disease. Certainly the old dictum “ once
syphilitic always syphilitic” is no longer
necessarily true and especially in relation
to the adequate treatment of early syphilis ;
indeed, both the medical profession and the
laity should realize the truth of this well
established fact.

o

IMPORTANT CONSIDERATIONS IN
CATARACT SURGERY*

GEORGE M. HAIK, M. D.f
Major, Medical Corps, Army of the United States

As is true of most other surgical proce-
dures, the act of cataract extraction is
merely one of the steps in the chain of
events by which the patient with this type
of pathologic change is relieved of his disa-
bility. The ophthalmologist who operates
without careful preliminary investigation
or who slights postoperative care is likely,
no matter how excellent his surgical technic
may be, to achieve results that are less than
satisfactory, or certainly that are less good
than he might have achieved had he given
more attention to these phases of the man-
agement of the case.

The remarks in this paper are based on
my personal experience in more than 300
cases of cataract extraction, as well as on
my personal observation of at least as many
more cases handled by other surgeons. Al-
though the recent literature of the subject
has been reviewed, references are omitted,
since the discussion is limited chiefly to

t From the 64th General Hospital and from
Charity Hospital of Louisiana at New Orleans.

* These observations are based on the author’s
experiences in civilian practice, not on experiences
in the Army.

346

Haik — Cataract Surgery

standard, non-controversial aspects of cata-
ract surgery.

PRELIMINARY STUDY OF THE PATIENT

Although cataracts, with the exception of
certain special varieties to be mentioned
later, occur chiefly in aged persons, the age
is seldom a factor in operation for cata-
ract. There is little more risk in operating
upon a patient 80 years of age or even older
than upon a patient in the fifth or sixth
decade, provided that his general physical
status is satisfactory and, in particular,
that his cardiovascular system is competent.
In other words, not the age of the patient
but his physical status determines the safe-
ty of operation and plays an important part
in its outcome.

The corollary of this fact is the necessity
of a preliminary examination of the patient
with cataract, which will supply informa-
tion upon four important points: (1) the
exact pathology present; (2) selection of
the time for operation; (3) selection of the
type of procedure to be employed; (4) de-
termination of the patient’s systemic status.
The first three of these considerations are
the business of the ophthalmologist. In the
study of the fourth the cooperation of a
competent internist is of great assistance
and often is indispensable.

Such conditions as glaucoma, detachment
of the retina, and choroiditis are frequent
complications of cataract, and the ophthal-
mologist must always be on the alert for
their presence. Intraocular tension should
always be determined. The condition of the
retina can be largely determined by light
perception, light projection, and the “two-
light test,” and the condition of the lens
can be determined by the use of the slit
lamp.

Systemic disease is usually considered a
contraindication to ocular surgery if the
general physical status of the patient is
such that the operation might precipitate a
serious crisis in the constitutional disease
or if the constitutional disease might seri-
ously influence the results of operation. In
such cases preoperative preparation is of
great importance. Hypertension is an ex-
cellent illustration of this statement. When-

ever extreme hypertension complicates
cataract, the patient must be treated by ab-
solute bed rest, supplemented by sedatives
and magnesium sulfate. It must be added,
however, that the condition of the retinal
vessels is as much a factor in hemorrhage
as is arterial hypertension.

Pulmonary conditions such as chronic
bronchitis, bronchiectasis or asthma are
associated with cough and are likely to be
aggravated by the recumbent position nec-
essary after cataract extraction. Cough al-
ways has a deleterious effect, and adequate
measures should be taken before operation
to control it.

Controllable diabetes is not a contraindi-
cation to cataract extraction, though it is
essential that the patient be on an adequate
and properly supervised diabetic regimen.
No change should be made in the treatment
before operation, and after operation, as
will be pointed out, every attempt should
be made to bring the diet to the caloric
value to which the patient has been accus-
tomed.

Opinions differ as to the wisdom of elimi-
nation of foci of infection before operation.
Even though such foci may not be the etio-
logic factor in the ocular disease, their pres-
ence is not conducive to rapid healing of the
surgical wound, and they should be correct-
ed so far as possible before operation. On
the other hand, it would not seem sound
logic to subject an elderly individual with
cataract to preliminary tonsillectomy or
some other major surgical procedure unless
the condition for which operation was pro-
posed was known to have a direct bearing
on the case. Uncompensated cardiac dis-
ease, hypertrophy of the prostate gland,
hemorrhoids, and even chronic constipation
may complicate the postoperative course
and therefore may require preoperative at-
tention.

The patient’s usual diet should be care-
fully investigated, since dietary deficiencies
are known to bear some relation to wound
disruption and delayed healing. A properly
balanced diet, supplemented, if necessary,
by vitamin therapy should be instituted
well in advance of operation.

Haik — Cataract Surgery

347

The general statement may be made that
patients with constitutional disease who re-
spond to preoperative measures may be sub-
mitted to cataract extraction with little
more risk than patients without such handi-
caps. Patients who do not respond to ade-
quate preparation fall into a different cate-
gory, and it may even be necessary to re-
fuse operation to a small group of such sub-
jects.

It is quite important that the surgeon ac-
quaint himself with the temperament and
mental status of his patient as with his
physical condition. Confidence between
them is essential. The patient must under-
stand what is expected of him and what, in
turn, he may expect of his physician. If he
realizes the importance of his own behav-
ior, if he is confident that he will experi-
ence little or no pain, if he trusts the abil-
ity and judgment of his surgeon, he will al-
most invariably behave well during opera-
tion and will furnish the required coopera-
tion during convalescence.

From the standpoint of asepsis, many au-
thorities believe that special preoperative
measures should be employed. Some apply
a trial bandage for varying periods of time
before operation. Some advise irrigations
with various solutions or use yellow oxide
of mercury ointment or instillations of
argyrol. Some employ foreign protein ther-
apy for several days before operation or
use triple typhoid vaccine. I do not per-
sonally believe that these or any other meas-
ures are necessary if one is certain that the
conjunctiva and lacrimal sac are clean and
if the conjunctival smear is negative.

SURGICAL CONSIDERATIONS

As has already been implied, two major
surgical problems confront the surgeon in
every case of cataract extraction, namely,
when to operate and what type of procedure
to employ. In general, the decision as to
when to operate depends upon the variety
of cataract with which one is dealing.

The most favorable time for operation
for senile cataract has arrived when the pa-
tient can no longer get about comfortably
and can no longer 'Carry on his usual occu-
pations. Now that improved methods of

intracapsular and extracapsular extraction
have been devised, it is no longer necessary
to wait until a marked degree of incapaci-
tation has set in, and the loss of time from
work can be minimal.

The patient with monocular cataract
should be operated on as soon as cataract
maturity is reached for three reasons : In
the first place, binocular vision is better
and safer than monocular vision. In the
second place, the longer the operation is de-
ferred the greater is the age of the patient
and the greater is the possibility of systemic
complications. Finally, the sooner the op-
eration is performed the less is the risk of
secondary glaucoma and iritis from cata-
ract hypermaturity.

In the patient with bilateral cataract the
question of operation on the second eye
often arises after a good result has been
obtained on the first eye. In my own opin-
ion, there is no question of the wisdom of
the second operation. Unless some serious
contraindication has developed, extraction
of the second cataract should follow prompt-
ly the extraction of the first.

The time at which operation should be
performed in congenital cataract depends
upon whether the opacity is limited to the
pole or extends to the nucleus. When com-
plete visual obscurity is present it is best
to operate as promptly as possible, even as
early as the third month of life, because
otherwise central fixation will not develop
and ocular nystagmus will result. If vision
is not entirely obscured, prompt operation
is less urgent and operation may be post-
poned, if desired, until early childhood.

In traumatic cataract which is the result
of a penetrating injury, with extensive
damage to the lens, it is best to remove as
much of the lens as possible immediately
upon seeing the patient, provided that not
more than eight hours have passed since
the injury. After that time, and always
if an inflammatory reaction has been set
up, it is wiser to delay removal of the lens
substance until the inflammation has been
controlled.

Dinitrophenol cataract should be ob-
served closely, and the lens should be re-

348

Haik — Cataract Surgery

moved promptly if signs of increased in-
traocular tension appear; otherwise an
acute glaucoma may develop.

It is difficult to make dogmatic state-
ments about cataracts with healed cyclitic
changes, many posterior synechiae, and
thickened capsules. If vision is so poor as
not to be useful at all, operation can be car-
ried out six or eight months after the pro-
cess has subsided. When vision is still use-
ful, the problem arises as to whether one
should operate with the hope of improving
it still further or should refrain from oper-
ation for fear of stirring up a devastating
inflammation. Each case of this kind must
be settled on its own merits.

TECHNICAL PROBLEMS

From the standpoint of technic, the sur-
geon must choose between corneal section
or a conjunctival flap, between combined
extraction or preliminary iridectomy, and
between simple extracapsular extraction or
intracapsular extraction. The object of all
these procedures is to achieve for the pa-
tient the best possible result with the least
possible risk, and often conditions present
in the individual case determine the pro-
cedure to be employed. In the absence of
such determining factors, I myself have
come to believe that the choice of operative
technic should depend to a very large de-
gree upon the skill which the individual sur-
geon has acquired in some particular tech-
nic or in his own personal modification
thereof.

The question of when iridectomy should
be done is still a matter of vigorous discus-
sion in ophthalmologic circles. There are
many advantages in its performance as a
preliminary procedure. It increases the vis-
ual acuity of patients with immature cata-
ract. When subsequent extraction is car-
ried out, the most painful part of the opera-
tion has already been completed, and there
is no risk of hemorrhage into the anterior
chamber from the cut iris. It is of advan-
tage in cases of chronic simple glaucoma
associated with megalocornea and hyper-
mature cataracts, and it will usually pre-
vent the iritis which sometimes occurs when
combined operation is done. It aids in the

determination of the condition of the vitre-
ous and determines the presence of a prev-
ious uveitis. It is therefore an aid in prog-
nosis. It permits the surgeon to become ac-
quainted with the reaction of his patient to
the surgical procedure, and it permits the
patient to become somewhat oriented in the
operating room, though an apprehensive in-
dividual may be made more nervous at the
thought of a second operation. The chief
disadvantages of preliminary iridectomy
are that it involves two penetrations of the
ocular coats, with the added risk of exogen-
ous infection, and that the two periods of
hospitalization necessarily increase the pa-
tient’s expense.

Iridectomy facilitates intracapsular oper-
ation if that particular technic is employed.
If the extracapsular procedure is employed,
it makes removal of the cortex easier and
furnishes more space for sweeping the cor-
tex out of the anterior chamber. In both
procedures it serves to reduce the incidence
of prolapse of the iris. Some surgeons ad-
vise it as a routine unless the operation is
performed for cosmetic purposes in a young
subject. To me, the chief disadvantages of
iridectomy are of little consequence. They
are: (1) the cosmetic result, that is, the
irregularity of the pupil, and (2) the in-
ability of the iris to regulate the amount of
light entering the eye.

Although the intracapsular operation has
many advocates, the extracapsular opera-
tion is generally considered the procedure
of choice in juvenile, congenital, traumatic,
and secondary cataracts. It is also of ad-
vantage in cataracts in bulging eyes, cata-
racts complicated by glaucoma, and glau-
comatous cataracts, as well as in cases as-
sociated with cough, asthma, high blood
pressure, high myopia and fluid vitreous.
One-eyed and excitable individuals seem to
do better when this technic is used, and
some advocate its routine use in patients
under 50 years of age whose zonular fibers
are likely to be rather strong. Many writers
feel that it is indicated in the morgagnian
type of cataract and other hypermature
cataracts and in senile cataracts in the in-

Haik — Cataract Surgery

349

tumescent stage, because of the difficulty
of grasping the tense capsule.

My own preference is for the extracap-
sular procedure which creates and leaves in-
tact a large conjunctival bridge. McRey-
nolds either divides the bridge, using su-
tures which he retracts to the side, or leaves
the bridge intact, making his assistant
grasp its lip and pull it down and forward
over the cornea, these maneuvers answering
the frequent objection to the bridge that it
creates difficulties in the performance of
the intracapsular operation. On the other
hand, the use of the bridge has several ob-
vious advantages. It prevents inversion or
eversion of the corneal lip. It facilitates
rapid removal of the speculum should this
become necessary. It helps to prevent the
corneal lip’s being caught by the upper lid
during the operation and in postoperative
dressing. My own impression is that heal-
ing is more rapid and closure of the wound
is more prompt when the bridge is present
postoperatively.

Although, along with most other writers
on the subject, I prefer the extracapsular
technic, it must be granted that the intra-
capsular procedure has certain advantages.
Earlier operation may be performed when
it is used, a second operation with its pos-
sible complications is avoided, and iritis
does not develop. The great disadvantage
of the technic is the high incidence of the
loss of vitreous and the accompanying com-
plications, chiefly prolonged healing with
wrinkling of the cornea, detachment of the
retina, delayed uveitis, secondary glaucoma,
and panophthalmitis.

Regardless of the technic selected, the
most important part of the operation is the
character of the section. The judgment of
the surgeon is dependent upon his knowl-
edge of the pathologic changes in the dis-
eased eye, especially his knowledge of the
size and consistency of the lens, the depths
of the anterior chamber, and the zonular
relationship of the capsule.

POSTOPERATIVE CARE

Postoperative care in cataract largely re-
solves itself into close observation by the
surgeon, supplemented by competent

nursing. Following operation the patient
is kept on his back for a period of 24 hours,
with his head on a pillow, to reduce the in-
tracranial blood pressure. At the end of
this time he is allowed to turn on the sound
(unoperated) side and is permitted a sec-
ond pillow. Since movement of the facial
and jaw muscles is undesirable, he is fed a
liquid diet, preferably for four or five days,
though as already intimated it may be nec-
essary to violate this rule in the case of
diabetic patients, whose diet must be
brought to its normal caloric value as
promptly as possible. Small doses of min-
eral oil are given twice daily. Sedatives
are used if the patient is nervous or ir-
ritable.

If nausea occurs following operation, the
bandage is removed from the sound eye, the
patient is placed on a backrest on the sound
side, and a sedative is administered. Back-
ache is more often complained of than local
pain and can be avoided by furnishing ade-
quate support, both on the operating table
and after the patient is returned to bed. It
is sometimes caused by an accumulation of
gas in the lower bowel. If the application
of heat is not effective, a rectal tube may
be inserted, especially when distention is
present.

Under ordinary circumstances the eye
is left undisturbed for 48 hours after oper-
ation. Then the bandage is removed, the
wound is dressed, atropine is instilled into
the eye and the bandage is re-applied. On
the third day eserine (0.5 per cent) is in-
stilled into the eye. Thereafter the wound
is dressed daily. The patient is usually per-
mitted to leave the hospital on the tenth
day, at which time he is warned of the im-
portance of protecting the eye and is told
of the serious complications which may fol-
low a slight blow to the eye or head, or even
any sudden jarring. He is required to wear
a bandage at night for at least a month
after operation.

OPERATIVE AND POSTOPERATIVE COMPLICATIONS

Regardless of the surgeon’s skill and of
his knowledge of local anatomy and of the
pathologic changes in the special case, un-
foreseen situations may occur, both during

350

Haik — Cataract Surgery

operation and afterward, which tax his
judgment to the utmost. These situations
are chiefly due to the pathologic conditions
present but may be aggravated by an un-
wise choice of procedure. Among the most
important of these complications are the
following :

Hemorrhage : Postoperative hemorrhage
is a frequent complication, especially in
diabetic subjects and in cases of vascular
disturbance of the uvea. It arises most
often from the vessels of the limbus and less
frequently from the iris. Hemorrhage into
the anterior chamber is not usually serious,
but the same statement cannot be made con-
cerning choroidal or expulsive hemorrhage.
This type, fortunately, is unusual, for it
practically always destroys the eye. Wheth-
er it occurs at the conclusion of the incision
or is delayed until as late as the tenth post-
operative day, it seems to depend upon the
degree of vascular degeneration present in
the choroid.

Vitreous Loss : This is a complication that
in some cases is unavoidable. Liquid vitre-
ous, the use of too much pressure, and at-
tempts at expression in an uncooperative
patient are all conducive to it. The presen-
tation of the vitreous immediately follow-
ing the completion of the section is a serious
complication which requires immediate but
at the same time deliberate action. My own
plan, when it occurs, is to lift the speculum
carefully and then to close the lids gently
for a period of two or three minutes. At
the conclusion of this time, the upper lid is
lifted with a muscle hook and the eye is
examined, the subsequent procedure being
determined by the findings.

Ruptured capsule associated with vitre-
ous loss is one of the most serious compli-
cations of the intracapsular operation. The
bursting of the capsule does not resolve the
operation into simple extraction with cap-
sulotomy. The posterior lens capsule has
been dislocated, and unless the capsule and
retained cortex can be removed entirely
with the capsulotomy forceps, a very dense
cataract will be the result. Even if the cap-
sule has been removed, the difficulty of

milking out flocculent cortex without fur-
ther loss of vitreous will be considerable.

Glaucoma : This complication may result:
(1) from prolapse of the iris or lens cap-
sule, with healing in the wound, or (2)
from the ingrowth of epithelium into the
anterior chamber which, by epithelization
of the filtration angle, reduces filtration
and brings about a resulting increase in in-
traocular pressure. Another possible cause
is the injudicious use of mydriatic and myo-
tic drugs after operation. Needling, al-
though considered a simple procedure, ac-
tually involves quite as much hazard as the
original extraction because it causes excita-
tion within the closed eyeball, without at
the same time provision for the safety of
drainage. I personally know of no condition
in cataract work which is more dangerous
to the eye and more difficult to treat suc-
cessfully than postoperative glaucoma.

Iritis : Iritis occurs much more frequently
after the extracapsular than after the intra-
capsular technic. Possible causes include
the leaving of the lens cortex or capsule
remnants in the anterior chamber, trauma,
circulatory disturbances, adhesions of the
iris in the wound, increased intraocular ten-
sion, and hemorrhage into the anterior
chamber.

Rupture of the Wound: This is a grave
complication which may be caused by trau-
ma or is occasionally observed in restless
patients, who turn in bed unaided during
the first few hours after operation. Some
authorities believe that vitamin C defic-
iency may be a factor. The accident may
result in adhesions, incarceration, or pro-
lapse of the iris or vitreous, collapse of the
anterior chamber, or hemorrhage into the
anterior chamber with subsequent iritis.

Prolapse of the Iris : This also is a serious
complication, since the smallest degree of
prolapse is a potential source of danger as
well as a constant source of pain and dis-
comfort. It requires further operative
measures for its treatment.

Sympathetic Ophthalmia.: This is one of
the most disastrous and disappointing re-
sults which can follow cataract extraction.
Fortunately, it is not frequent.

Alexander — Monocular Proptosis

351

Retinal Detachment : When retinal de-
tachment has occurred very little can be
done to bring about re-attachment, opera-
tive results being generally disappointing.
The accident can be prevented, however, by
elimination of excessive vitreous loss and
by prevention of chronic uveitis with sub-
sequent softening of the globe.

Infection : Purulent inflammation of the
eye following cataract extraction may be
exogenous or endogenous, the former va-
riety being most frequent. Treatment is
seldom satisfactory, and the eye is usually
lost, though the outlook is somewhat more
hopeful since the introduction of the sul-
fonamide drugs.

Asteroid Hyalitis : This is a rare compli-
cation and is compatible with reasonable
vision.

PROGNOSIS

The chances of recovery in the uncompli-
cated cases of cataract are generally good,
and the patient is usually able to resume his
former occupation to a moderate degree if
not entirely. On the other hand, it is not
reasonable to expect notable improvement
following cataract extraction in a patient
who gives a story of visual changes before
the formation of the cataract, and such an
outcome is practically never observed.

SUMMARY

1. The best results in cataract extraction
are secured by careful preliminary study of
the patient, correction or control of asso-
ciated constitutional conditions, and con-
stant postoperative observation supple-
mented by adequate nursing care.

2. From the surgical standpoint the chief
problems are when to operate and what
special procedure to adopt. The advantages
and disadvantages of the various technics
are briefly discussed.

3. The complications of cataract extrac-
tion are frequently very serious, and meas-
ures to prevent them are usually more suc-
cessful than measures to control them.

4. The results in uncomplicated cataracts
are usually good after extraction. If the
impairment in vision has existed before the
formation of the cataract, naturally its re-

moval will not materially improve the pa-
tient’s condition.

o

SINUS DISEASE PRODUCING
MONOCULAR PROPTOSIS*

WITH CASE REPORTS AND WITH SPECIAL
REFERENCE TO MUCOCELE (PYOCELE)

LUCIAN W. ALEXANDER, M.D.

New Orleans

Mucocele or pyocele, of which monocular
proptosis is perhaps the most striking mani-
festation, presents certain rather curious
aspects. The older texts, such as those of
Skillern1 (1923) and Hajek2 (1926) discuss
the condition in considerable detail; there
are ten separate references to it in Hajek’s
text. Recent texts, such as Thomson and
Negus’3 (1937), Morrison’s4 (1937), and
Ballenger and Ballenger’s5 (1943), pay only
scant attention to it. In the English litera-
ture authoritative articles on the subject
were written by Logan Turner6 and by
Howarth (Hunterian Lecture)7 in 1921.
But since 1935 the literature has contained
only occasional case reports, though with
the technical improvements which have re-
cently occurred in roentgenology, one might
have expected an increase in the discussion,
at least from the diagnostic standpoint.

Without a complete review of the litera-
ture, which I have not attempted, it would
be impossible to state the exact number of
recorded cases. There are duplications and
overlappings in the various collected series.
In 1921 Dabney8 was able to collect 74 cases
from a review of fifty-eight articles writ-
ten since 1881. Beyer9 states that Gerber
(to whose original article I have not had
access) collected 169 cases in 1909, includ-
ing some of the cases later collected by Dab-
ney. The largest personal series on record
is the 10 cases reported by Logan Turner
in 1907, the 14 cases reported by Howarth
in 1921, and the 30 cases reported by Boen-
ninghause (cited by Beyer) in 1923. I
have personally observed six cases in adults,

*Read before the sixty-fifth annual meeting of,
the Louisiana State Medical Society in New Or-
leans April 24-26, 1944.

352

Alexander — Monocvla r Proptosis

in addition to the two cases in children
which I am reporting in this communica-
tion, and the comment is probably warrant-
ed that while the condition is not common,
it is not at all rare.

Conflicting statements are made as to
the age at which the disease occurs, a dis-
crepancy to which Howarth called atten-
tion in his Hunterian Lecture. Dabney, on
the basis of the 74 cases which he had col-
lected, stated that its occurrence in youth
is one of the distinguishing characteristics
of mucocele. Garretson,10 without making
clear on what grounds he had formed his
opinion, stated that it was a disease of later
middle life. In the 25 cases which i have
located in a casual survey of the literature
since 1921, the date of Dabney’s report, the
age range was from 12 to 80 years, one
patient being described merely as “elderly.”
All but four of the patients were over 20
years of age, and 11 were over 35 years of
age. Because the disease is known to be of
slow development, I should be inclined to
take the position that it is more frequent
in adult than in early life. So far as I have
been able to gather from the literature
available to me, the two patients I am re-
porting herewith, in one of whom the muco-
cele was classified as incipient, seem to be
among the youngest in whom the disease
has been observed.

I am presenting these case reports in
greatly abbreviated form, since a sufficient
number of instances are now on record to
make a great deal of detail unwarranted.
The ophthalmologic aspects of both cases
will be discussed by Dr. W. B. Clark, whom
I called in consultation in the first case, and
who, because he recollected it, called me
into consultation in the second, in which he
himself had been called as consultant by
Dr. Gilbert C. Anderson.

CASE No. 1

D. B., a white girl 14 years of age, had always
suffered from colds. In the fall of 1942 she began
to complain of headaches, and the left eye began to
swell and protrude intermittently; the symptoms
lasted only for a day or two at a time, but re-
curred every seven or eight weeks. The symptoms
and signs were regarded as a phase of the girl’s
habitual colds, and no attention was paid to them.

They disappeared entirely during the late spring'
and summer of 1943, but recurred in the fall cf
that year, at which time the patient was brought
to my office. All symptoms except those stated
were denied, and physical examination was essen-
tially negative except for a rather marked prop-
tosis of the left eye and the presence of a small,
hai d, rounded, definitely localized mass, about 21
cm. in diameter, in the left inner canthus.

Laboratory examinations were essentially nega-
tive. Roentgenologic examination of the skull in
the anteroposterior position showed some cloudi-
ness in the right maxillary sinus. The left intra-
orbital foramen was considerably larger than the
right foramen. The lateral view revealed an ap-
parent hyperostosis of the vault, more prominent
in the region of the frontal bone.

The tentative diagnosis of mucocele of the left
frontal sinus, with probable extension of the
ethmoid sinus, was confirmed at operation, at
which the Lynch radical frontal operation was car-
ried out under nitrous oxide ether anesthesia. When
the periosteum was elevated a pyoc-ele presented
itself just medial to the left inner canthus and
extending from the frontal sinus into the ethmoid
labyrinth. It ruptured on the first manipulation
and about 2 drams of pus was removed. Following
excision of the sac the frontal sinus was curetted
and the frontal process of the maxillary bone was
trimmed sufficiently to permit a large rubber tube
drain to be inserted through the nose up into the
frontal sinus. Sulfanilamide was placed in the
wound before closure.

VASE No. 2

A white boy, 11 years of age, began to complain
of generalized headaches in the fall of 1942. Soon
afterward swelling of the left upper lid was ob-
served, and still later fixation of the left eyeball,
associated with double vision. The boy was hos-
pitalized for 14 days and was treated with one of
the sulfa drugs. The headaches were completely
relieved thereafter, and the swelling of the eyelid
also disappeared, but it recurred every month cr
two, and was later associated with marked prop-
tosis. The eyeball remained fixed. There was
nothing of significance in the previous history ex-
cept for frequent colds and asthma during the
first two years of life.

The boy came under the attention of Dr. Gilbert
C. Anderson in February, 1944, because it was
suspected that a brain tumor was the cause of his
symptoms. Dr. Clark was asked to see him in con-
sultation because an orbital tumor was suspected,
and still later I was called in consultation because
a mucocele was suspected.

Physical examination was essentially negative
at this time except for the ophthalmologic findings
already described. Laboratory examinations were
also essentially negative. Radiologic examination
of the skull (figs. 1, 2) showed considerable en-

Alexander — Monocular Proptosis

353

largement of the left sphenoidal fossa as a result
of irregular erosion of the superomedial wall. The
roentgenologist considered that this implied, in ad-
dition to destruction of the frontal bone near the
apex of the orbital roof, a possible communication
with the posterior ethmoid air cells. The left optic
foramen was larger than the right. The left
sphenoid and left ethmoid sinuses were hazy and
the frontal sinuses were little pneumaticized. The
other sinuses were apparently well aerated.

The roentgenologist did not regard the findings
as definite enough for diagnosis, but suggested as
possibilities meningioma with secondary involve-
ment of the orbital apex, to be excluded by pneu-
mography; tumor or granuloma of intraorbital
origin; and a primary lesion of the posterior
ethmoid labyrinth, which might be either a tumor
or a mucocele.

Fig. 1. Anteroposterior roentgenogram of si-
nuses in case of incipient mucocele (see text for
detailed description).

Fig. 2. Anteroposterior roentgenogram of skull
in case of incipient mucocele (see text for detailed
description) .

Exploration under nitrous oxide ether anesthesia
revealed no abnormality of the left frontal sinus.
The ethmoid labyrinth in both the anterior and
posterior portions was full of polypoid and granu-
lation tissue. The Lynch radical frontal operation
was carried out, as in the first case, the ethmoid
space was thoroughly curetted, and the frontal
process of the maxillary bone was partially re-
moved, to permit the introduction of a large rubber
tube for drainage. The pathologic report on the
excised tissue was polypoid and chronic inflamma-
tory tissue.

Recovery was smooth and the boy at present
has no proptosis or other deformity. A possible
allergic background was suspected in this case, be-
cause of the polypoid character of the contents of
the ethmoid labyrinth, but a complete check from
this standpoint has shown only insignificant reac-
tions to all of the substances tested. Culture of
the nasal secretion revealed Staphylococcus aureus,
from which an autogenous vaccine was made, but
it has been used too brief a time to permit any
statement as to results.

COMMENT

The first of these cases was a clearcut in-
stance of pyocele involving both the frontal
and ethmoid sinuses. The second case I
believe was an incipient mucocele, which
has been aborted by correction of the cir-
cumstances which would have favored its
further development. In each case it is to
be assumed that the disease must have be-
gun to develop for a considerable period of
time before symptoms were manifest,
though the youth of each patient necessarily
limited the duration of the pathologic
changes.

It should be emphasized that in each
case the symptoms and findings were ex-

354

Alexander — Monocular Proptosis

actly as stated, and that the physical find-
ings were limited to the orbital cavity.
There was no complaint of pain and tender-
ness above the eyebrow, no nasal discharge,
and no auditory symptoms. Transillumina-
tion and other examinations furnished no
diagnostic aid, and no etiologic factor could
be demonstrated. The Lynch radical front-
al operation permitted full exposure and
adequate curettage of the affected spaces,
and left no deformity, the scar in each case
being minimal and evident only on close in-
spection. In each case the ophthalmologic
status is now entirely normal.

DISCUSSION

Etiology: None of the theories of etiol-
ogy advanced to explain mucocele and pyo-
cele is applicable to all cases, and for that
reason definitions which introduce specific
or implied concepts of causation are im-
proper. Logan Turner, for instance, de-
fined mucocele as “a distension of one or
more of the walls of the cavity, and an ac-
cumulation within it of a mucous secretion
resulting from obstruction of its outlet.”
As will be pointed out later, the outlet was
not obstructed in many of the reported
cases, the secretion is not usually mucoid,
and the train of events is accumulation of
secretion followed by distention of the bony
walls, rather than vice versa, as this defi-
nition would suggest.

The important theories of the etiology of
mucocele may be summarized as follows:

1. Trauma: This theory is naturally

not applicable to the cases (which include
most of the reported cases) in which no his-
tory of trauma can be obtained. It is also
possible that in some cases the physical evi-
dence of mucocele was present and was ig-
nored by the patient until some injury of
the region called his attention to it. In one
of the cases reported by Chamberlin and
Parry,11 for instance, the negro woman
stated that a swelling in the internal can-
thus had been present before her injury,
after which, however, it had become larger.

On the other hand, as Dabney pointed
out, it is not unreasonable to assume that a
blow over the internal angular process, in
the region of the nasofrontal duct, might

cause closure of the natural exit for secre-
tions, particularly in young persons, whose
sinuses are small and rudimentary and
whose bones are easily bent. Howarth,
who believed trauma to be responsible for
four of his 14 cases, postulates a special
configuration of the ethmoid cells, some of
which, instead of being protected, as nor-
mally, by the ascending process of the su-
perior maxilla, apparently lie much farther
forward, in front of the lacrimal process.

Demaldent’s patient (cited by Dabney)
observed his mucocele only two days after
he had dived six times into the Seine to
rescue a drowning man, but in many cases
the symptoms occurred so long after the in-
jury that the correlation seems somewhat
unrealistic.

2. Occlusion of the ostium of the sinus
for various reasons, including trauma, as
already mentioned; obstructive scar tissue
from previous inflammations; congenital
absence of communication between the nose
and frontal sinus; and congenital narrow-
ing of the duct, which would predispose to
catarrhal inflammation and obstruction.
The lumen, as already pointed out, is patent
in many cases, but Turner is of the opinion
that in such instances temporary closure of
the ostium may previously have occurred
and that later, after the lumen has again
become patent, the retained secretions are
too viscid for free drainage.

3. Cystic dilatation of a mucous gland
or cystic degeneration of the mucosa. Dab-
ney believed that he had proved this theory
in one of his personal cases, and Johnson12
stated that it can be confirmed by histologic
examination. Lobell,13 who believes that all
mucoceles can be explained on this basis,
advances the following arguments to sup-
port his position: (a) Mucocele is rare as
compared with ostial occlusion from hyper-
trophy, hyperplasia, neoplasia, and polypoid
changes. The latter changes, it will be re-
membered, were present in the second case
I am reporting, and I believe would have
gone on to continued degeneration if opera-
tion had not been performed, (b) A cystic
mass is invariably found in the floor of the
sinus, in the immediate vicinity of the ori-

Alexander — Monocular Proptosis

355

fice of the nasofrontal duct, whenever an
incipient mucocele is discovered by x-ray
and the sinus is trephined. The author sup-
plies no details, and the assumption is that
this has been his personal experience, (c)
The frequency, for anatomic reasons, of
mucoceles in the frontal as compared to the
maxillary sinuses, (d) The characteristic
absence of pain in mucocele, as compared
with the characteristic pain of ostial occlu-
sion. Since the stage of occlusion, which
is the terminal stage of mucocele, is pre-
ceded by degeneration of the mucosa, the
explanation for the absence of pain is that
the nerve terminals have lost their sensi-
tivity for the perception of pain stimuli, as
the result of the previous process.

4. Cavanaugh’s14 theory that mucoceles
originate in misplaced ethmoid cells, which
undergo pathologic changes as the result of
vitamin or endocrine imbalance, has no
other supporters so far as I know. The
same author, again with no other apparent
support, lists as possible predisposing
agents dust, fumes, vapors, gases, and
toxic substances.

Pathologic Changes: A mucocele resem-
bles a cyst in its gross characteristics. His-
tologically, according to Johnson, it is a
thin-walled sac made up of fibrous tissue
with edema, and lined by low cuboidal or
stratified columnar epithelium, in contrast
to the normal pseudostratified ciliated col-
umnar epithelium of the frontal sinus and
ethmoid cells. Although the contained se-
cretion may vary widely in its characteris-
tics, most writers emphasize that it is thick-
er than the normal mucoid secretion of the
sinuses, being tenacious or gelatinous, and
difficult to remove. Dabney states that it
comes away in “wormlike” masses. In
Pimental’s case (cited by Sallinger15) as
in my own second case, it was polypoid in
character. The color is variously described
as yellow, amber, brown, gray, pinkish-
gray, and red-streaked or black-streaked.

Bone changes vary from moderate to ex-
treme in advanced cases. In early cases —
the term early always being used relatively
in this condition — they may be absent or
slight, as in my own cases. Whatever may

be the etiologic factors responsible for
mucocele, the ultimate bony changes are of
mechanical origin and are the result of
pressure within a closed space. It is the
constancy rather than the degree of the
pressure which results in erosion and other
bone changes, including ruptfire, if the
pressure is not relieved by surgical meas-
ures. Relative enlargement of the affected
cavity, as compared with the cavity on the
opposite side, is one of the diagnostic crite-
ria, and was observed in both cases which
I am reporting. One of the walls, however,
usually gives way before enlargement of
the bony cavity becomes extreme.

Skillern observed that it is conceivable
that continued secretion can cause bulging
of the walls of the ethmoid and maxillary
sinuses, which are very thin, but almost in-
credible that the anterior wall of the frontal
sinus should give way for this reason. Para-
doxical as it may seem, however, the weaker
posterior wall seems to resist pressure bet-
ter than the stronger anterior wall. The
defect most usually occurs in the wall of
the sinus overlying the orbit, after which
the distending sac pushes itself into the
upper medial orbit and displaces the globe.
In a smaller number of cases the floor of
the sinus remains intact and erosion and
rupture occur posteriorly, with exposure of
the dura, which sometimes is extensive.

External rupture sometimes occurs, as
in Smith’s16 case, in which rupture of the
left frontal sinus occurred through the up-
per eyelid two weeks before the patient
sought medical advice. The anterior walls
of both sinuses were removed at operation,
which left nothing to sustain the underly-
ing tissue, so that immediate cosmetic ef-
forts were useless. In Moure’s case (cited
by Hajek) a mucocele of the ethmoid laby-
rinth grew to the size of a hen’s egg, perfo-
rated the nasal septum, produced in a dias-
tasis of the nasal bones, and projected like
a hernia into the opposite sinus. In Dow-
man’s17 “giant” mucocele the enlargement
of the right frontal region, including the
supraorbital ridge, was 7 cm. transversely
and 5 cm. vertically. In this case the pos-
terior bony wall was replaced by pulsating

356

Alexander— Monocular Proptosis

dura, and the supraorbital plate and in-
ferior wall were respectively absent and re-
placed by intraorbital structures.

A pyocele differs from a mucocele only
in that infection is introduced or is present
from the onset ; the pathologic process is
otherwise the same. Bacteriologic exami-
nation of the contents of the usual mucocele
is negative, but various organisms, includ-
ing pneumococci, have been reported in pyo-
celes.

Clinical Picture and Diagnosis: Because
of their slow growth and chronicity, muco-
celes may not give rise to symptoms for
long periods of time, and seldom give rise
to severe symptoms. As a result, the pa-
tient frequently puts off medical consulta-
tion for long periods of time — 15 to 18
years in some of the reported cases — and
most frequently comes first to the ophthal-
mologist because his chief symptoms are re-
lated to the eye.

The most constant complaint is headache,
usually frontal, varying from mild to se-
vere. Other symptoms, as listed by Dab-
ney, include a sense of weight, numbness in
the top of the head, fulness of the cheeks,
and a feeling that the two sides of the head
are different. Epiphora is not infrequent.
There is seldom a nasal discharge unless
intranasal rupture has occurred, and exam-
ination of the nasal structures is usually
negative. Constitutional symptoms, even if
the mucocele is converted to a pyocele, are
usually absent.

Mucoceles arising from the ethmoid laby-
rinth are located somewhat lower than the
frontal variety, and sometimes displace the
lacrimal apparatus, though the difference
in location is so slight as usually to be of
little diagnostic value. The displacement
of the eyeball in early cases seems to be
most pronounced when both the frontal and
ethmoid sinuses are involved, as in the first
case reported herewith, and least pro-
nounced when only the ethmoid labyrinth is
involved, as in the second case. In ad-
vanced cases the displacement may be so
extreme that the eyeball is forced out of
the socket; in Barthausen’s classic case
(cited by Skillern) the eyeball was disol-

cated almost below the nasal aperture. Since
the mass is external to the orbital contents,
movements of the eye are not usually af-
fected. Diplopia may be an early symptom,
as in my second case, as the result of slight
alteration of the visual axis due to displace-
ment of the contents of the orbit, but is
usually a later symptom. Serious impair-
ment of vision is the rule in neglected cases.
Edema of the eyelid, which feels stiff on
palpation, is frequently associated with
proptosis.

Diagnosis is made tentatively on the
basis of the history and physical findings,
supplemented by roentgenologic examina-
tion, which is usually diagnostic, particu-
larly in late cases. The radiologic changes,
as outlined by Hartung and Wachowski,lx
include variations in the density of the
sinuses and abnormalities of the contour
and structure of the sinal walls, depending
upon the size, shape and location of the
mucocele and the extent to which it has pro-
duced pressure changes in the form of ero-
sion, displacement, or reactionary changes
in the surrounding structures.

In cases without bone erosion the roent-
genologic changes are similar to those found
in the ordinary retention cyst. When bony
changes have occurred, however, the picture
is characteristic. The gross outline of the
affected sinus is usually slightly larger than
on the other side, and the density over the
sinus is decreased. The borders lose their
septate or scalloped appearance. The mar-
ginal densities become rarified, smooth and
regular, this being perhaps the most char-
acteristic finding. If distention has been
rapid, the border may show roughening
and areas of bony deficiency. The orbital
roof may be flattened and pushed down,
and may present a defect. The ethmoidal
cells may be encroached upon, and lateral
exposure may reveal considerable unsus-
pected encroachment upon the anterior
cranial fossa. If the process has been slow,
there may be areas of increased density
along the margins or superimposed upon
the sinus cavity, which represent reaction-
ary bone formation.

Alexander — Monocular Proptosis

357

Shadows may be so dense as to suggest
osteomata. Changes indicating increased
radiopacity are usually of greater diagnos-
tic value than those of increased density,
which are suggestive of mucocele only when
accompanied by secondary changes in sur-
rounding structures or when localized with-
in the sinus. Lateral and sagittal exposures
are useful in ruling out shadows due to
anomalous configurations of the sinuses or
abnormalities of neoplastic origin. Lipi-
odol injection also may be useful.

Hartung and Wachowski provide an ex-
cellent discussion of differential diagnosis,
which includes chiefly dermoid cysts, men-
ingocele, osteoma and fibrosarcoma. The
thirty-six possible conditions which must
be differentiated according to Lederer19 are
for the most part unimportant. Dermoid
cysts and meningoceles, both of which are
congenital, usually occur in the midline.
Osteoma and fibrosarcoma can be distin-
guished from mucocele by the fluctuant con-
sistency of the latter, which can be demon-
strated by cautious aspiration if necessary.
The monocular character of the proptosis
excludes Graves’ disease. The clinical dif-
ferentiation between mucoceles of the fron-
tal and the ethmoid sinus is usually impossi-
ble.

Therapy : Therapeutic measures are im-
perative, no matter how early the condition
is recognized, to prevent subsequent osseous
and tissue deformity, orbital changes, and
irreparable damage to the sight, which has
occurred in some of the recorded cases.
Furthermore, while the disease is ordinarily
mild and recovery after operation smooth,
this is not always true, particularly in late
cases. Luc (cited by Dabney) discovered,
after he had almost completed the operation
for mucocele, that his patient also had men-
ingitis and a brain abscess. Johnson’s pa-
tient, whose interfronta! partition had been
eroded away by the pathologic process, de-
veloped septicemia and meningitis after op-
eration, type XXVIII pneumococci being
isolated from the contents of the mucocele,
the blood stream, pnd the spinal fluid.

The subject of treatment is the removal
of the mucocele and the institution of

adequate drainage. This was formerly
achieved by the Killian or the Luc-Caldwell
operation, but is now accomplished, with
greater ease and without deformity, by the
Lynch radical frontal operation. An in-
tranasal operation is occasionally adequate
when only the ethmoid labyrinth is involved,
but usually some external procedure is nec-
essary.

If the exophthalmos has become so
marked that regression does not occur after
correction of the sinal disease, it should be
treated later by the Naffziger or the Sewall
operation. Plastic surgery may be neces-
sary after the primary operation in ad-
vanced cases in which external rupture and
extensive bone destruction have occurred.

SUMMARY

1. Mucocele (pyocele) is not rare but is
still sufficiently uncommon to warrant the
record of additional cases, two of which,
including one incipient case, are reported
herewith. Both occurred in children.

2. No theory of etiology is applicable to
all cases, and no etiologic factor was ap-
parent in these two cases. Trauma, occlu-
sion of the ostium of the sinus for various
reasons, and cystic dilatation of a mucous
gland or cystic degeneration of the mucosa
are the most important probable causes.

3. Orbital changes, the most striking of
which is proptosis, are the outstanding
findings in mucocele and pyocele, and are
the result of distention of the sinal spaces.
Bone changes in late cases may be very de-
structure, and external rupture is a possi-
bility. In the reported cases, both of which
were early, orbital changes were notable
but bone changes were minimal. The con-
stancy of the pressure within the sinus,
rather than the degree, is the background
of the pathology.

4. Symptoms related to the eye are the
most important phase of the clinical picture
of mucocele, and physical examination, ex-
cept in very advanced cases, is usually nega-
tive except for the orbital findings. Diag-
nosis is made on the clinical picture and is
confirmed by the radiologic findings.

5. Therapy should be instituted as soon
as the diagnosis is made, to prevent later

358

Alexander — Monocular Proptosis

bony and tissue deformity, which may be
extensive, and orbital changes, which may
result in serious impairment of vision. The
Lynch radical frontal operation accom-
plishes adequate drainage with minimal
scarring. It was used in both the reported
cases. Surgical correction of permanent
exophthalmos may be necessary in neglect-
ed cases, and secondary plastic procedures
must be employed if extensive bony destruc-
tion has occurred.

K E F E R EXCESS

1. Skillcrn, R. I-I. : The Catairrlial <inrl Suppurative Dis-
eas.'s of the Accessory Sinuses of the Nose, 1923, ed. 4.
Philadelphia and London, J. B. Lippincott.

2. Iia.iek. M. : Pathology and Treatment of the Inflam-
matory Diseases of the Nasal Accessory Sinuses. Trans-
lated and edited by J. I). Heitger and F. IC. Hansel, 1926,
ed. .1. St. Louis, The C. Y. Mosby Company.

2. Thomson. St. Clair, and Negus, V. E. : Diseases of
the Nose. Throat and Ear. Medical and Surgical. 1943.
titioners, 1937, ed. 4. New York and London. D. Appleton
Century Company Incorporated.

4. Morrison, W. W. : Diseases of the Nose, Throat and
Ear. 1938, Philadelphia and London. W. B. Saunders
Company.

5. Ballanger, \Y. I... and Ballenger, II. C. : Diseases of
the Nose. Throat and Ear, Medical and Surgical, 1943,
ed. S, Philadelphia, Lea A Febiger.

Turner, A. Logan: Mucocele of the. accessory nasal
sinuses. Edinburgh M. .1.. 22 (n.s.t :396, 481. 1907.

7. Ilowarth, IV. G. : Mucocele and pyocele of the nasal
accessory sinuses (Hunterian Lecture), Lancet, 2:744.
1921.

S. Dabney, Virginias.: Mucocele of the nasal accessory
sinuses : two cases of pansinus involvement with recovery
after interval operations. New York M. .1.. 114:619. 1921.

9. Beyer, T. E. : Pyocele of the frontal sinuses, Laryn-
goscope. 32:715, 1932.

10. Garretson, W. T. : Mucocele of the frontal sinus,
with tlie report of a case, Laryngoscope. 38:350, 1927.

11. Chamberlin, \Y. B., and Parry. T. L. : Mucocele as
a cause of proptosis. Report of six cases, Arch. Otolaryng.,
18:172, 1933.

12. Johnson. G. I.: Infected mucocele of the frontal
sinus, complicated by septicemia and meningitis, with
recovery. Arch. Otolaryng., 33:841. 1941.

13. Lobell. A.: Relationship between mucoceles and

cysts. Report of a cyst of the maxillary sinus, Arch.
Laryng.. 6 :546, 1927.

14. Cavanaugh, J. A.: Mucoceles of the frontal sinus,

I. a ryngoseope, 45:202, 1935.

15. Sailinger. Samuel: The paranasal sinuses. Review of
the literature for 1940. Arch. Otolaryng., 36:358, 1941.

1C. Smith, Harmon : Mucocele of the left frontal sinus,
Laryngoscope, 33 :108, 1923.

17. Dowman, C. ‘E. : Giant mucocele of tile frontal sinus,

J. A.M.A., 81 :1014, 1923.

18. Hartung, Adolph, and Wachowski, Theodore: Muco-
cele of the frontal sinus, with special reference to the
roentgen aspects and report of four cases, Am. .1. Roent-
gen.. 34:30. 1935.

19. I. ■derer. F. I.. : Diseases of the Ear. Nose and Throat.
Principles and Practice of Otorhinolaryngology. 1939, ed 2.
Phil, delphia. F. A. Davis Company. Publishers.

DISCUSSION

Dr. Shelly R. Gaines (New Orleans) : The first
case, R. D., was seen by me on February 7, 1942.
At that time the vision in the right eye was 20/25
and the vision in the left eye was 20/25. The vi-
sion in the left eye could not be improved with
glasses. Upon examination of the left eye there
was edema of the upper lid, proptosis of the globe
of 4 mm. A palpable firm mass could be demon-
strated along the inner upper rim of the orbit. The
fundus examination showed two diopters of papil-
ledema with marked engorgement of the veins.
When seen on April 12, 1944, the vision was right
20/20; left eye 20/20; accommodation 12.00 diop-
ters in both eyes. A PCB of 5'/2 cm. was presented.
The proptosis was reduced to less than 1 mm. The
ptosis was almost gone and engorgement of the
veins was much less and the swelling the upper lid
had disappeared.

The second case when first seen had a vision of
20/20 in each eye. The patient was near sighted.
The vision was corrected with glasses to normal.
There was a slight edema of the affected eyelid
and the globe was visibly displaced laterally. There
was 3 mm. proptosis. A smooth firm mass was
palpated along the inner and upper orbital rim.
No fundus changes were present. On November
24, 1943 the edema of the lid was much improved.
The lateral displacement of the globe was practi-
cally gone and the proptosis was much less.

Dr. Gilbert C. Anderson (New Orleans) : This
excellent report emphasizes the interest and im-
portance of rare and unusual conditions. The pa-
tient was an exceptionally strong and well built
boy of 12 who was active in athletics, specializing
in football, and to this football playing his mother
attributed all of his trouble. He had been having
intermittent attacks for about two years all pretty
much alike and characterized by severe headache
with nausea and vomiting; the tissue about the
eye would swell markedly but this swelling was
within the limits of the bony orbit and mostly in
the upper lid. There was very little swelling about
the periphery of the orbit. After a short time
there would occur a discharge of a large amount
of bloody mucoid material from the left nostril
and the attack would clear up, only to return at a
later date. Tentative diagnoses at home were
brain abscess and recurring hematoma. On exam-
ination I found no evidence of increase in the in-
tracranial pressure and no neurologic signs of a
localizing nature. I therefore thought of a neo-
plasm or inflammatory condition within the orbit
and roentenograms showed the changes described
by the essayist. I found this case to be of unusual
interest in its development and very gratifying in
its outcome.

Dr. L. W. Alexander (in closing) : I think one
of the things that these cases bring out is that we
should be on the lookout for them and when they
are found realize that they are worth while going

Pullen, Sodeman and Felknor — Rocky Mt. Spotted Fever

359

into and exploring because if you do not you are
going to get some tissue deformities and consider-
able loss of vision if not taken early. If taken
early I think we can save tissue deformity and
vision in these cases.

C

ROCKY MOUNTAIN SPOTTED FEVER

DIFFERENTIATION FROM TYPHUS FEVER
AND REPORT OF CASE

R. L. PULLEN, M.D.f
W. A. SODEMAN, M.D.*

AND

GEORGE FELKNOR, M.D.f
New Orleans

In the ten years intervening from Jan-
uary 1, 1934, to December 31, 1943, a total
of 145 cases of endemic (murine) typhus
fever were observed in the Charity Hospital
of Louisiana at New Orleans. Thus typhus
fever is seen sufficiently often in Louisiana
to warrant consideration in the differential
diagnosis of all acute infectious diseases ac-
companied by a rash. Rocky Mountain
spotted fever, on the other hand, is rarely
entertained in the diagnostic possibilities.
The purpose of this paper is to present a
report of the first case of Rocky Mountain
spotted fever diagnosed at the Charity Hos-
pital, and to describe the diagnostic aspects
of spotted fever as compared to typhus
fever.

An eastern type of Rocky Mountain
spotted fever was first identified in 1931 by
Badger, Dyer and Rumreich.1 Subsequent
studies of this disease show it to be clinic-
ally indistinguishable from the western va-
riety. There are, however, differences in
transmission of the two types. The west-
ern form of Rocky Mountain spotted fever
is conveyed to man by attachment and en-
gorgement of the wood tick, Dermacentor
andersoni, whereas most cases in the east-
ern and southeastern states are transmitted
by the dog tick, Dermacentor variabilis.
There is some evidence that the rabbit tick,
Dermacentor parumapestus, is infected

fFrom the Departments of Medicine and ^‘Pre-
ventive Medicine, School of Medicine, Tulane Uni-
versity of Louisiana, and the Charity Hospital of
Louisiana at New Orleans.

with a virus of low virulence and since the
rabbit tick is distributed widely, may con-
ceivably serve as a source of infection. In
nature Haemaphysalis leporis-palustris is
an important vector for rabbits. Investiga-
tions in the Gulf Coast area in Texas2 indi-
cate the possibility of other ticks as vectors
for Rocky Mountain spotted fever in this
area. There are infections present in other
ticks, but to date they have not assumed
epidemiologic importance. No information
has been definitely established concerning
the percentage of ticks infected in the east-
ern and southeastern states. Random
studies3 throughout United States permit
the conclusion that only 1 per cent of ticks
are infected in most areas, although in cer-
tain localities and at certain times the per-
centage of ticks infected may be as much
as 11 per cent. Thus, Rocky Mountain
spotted fever is essentially a rural disease
and occurs during the period of greatest
tick activity, that is spring and summer.
Endemic (murine) typhus fever, being
transmitted chiefly by the rat flea, Xenop-
sylla cheopis, is most prevalent during the
summer and fall. The greatest incidence
of endemic typhus occurs in those persons
frequenting rat-infested habitations, hence
is often seen in those handling foodstuffs.

The history of a recent bite by a tick or
crushing of a tick is oftentimes of consider-
able diagnostic significance in Rocky Moun-
tain spotted fever. The etiologic agent,
Dermaceritroxenus rickettsii, gains entrance
to the body by direct injection from the sali-
vary glands of the tick during the process
of feeding. Occasionally, contamination of
the fingers by infected viscera of crushed
ticks may lead to a gastrointestinal route
of infection. Ample evidence suggests that
the rickettsiae of both Rocky Mountain
spotted fever and typhus fever may pene-
trate the unbroken skin and a few cases
have been ascribed to a conjunctival infec-
tion.

The etiologic agent of Rocky Mountain
spotted fever, Dermacentroxenus rickettsii,
is morphologically similar to that causing
typhus fever, Rickettsia prowazeki. D. rick-
ettsii, however, possesses the unique prop-

360

Pullen, Sodeman and Felknor — Rocky Mt. Spotted Fever

erty of invading nuclear substance whereas
R. prowazeki grows massively in the cyto-
plasm but does not invade the nuclei.
Smears from the scrotal sacs of infected
guinea pigs and tissue cultures may enable
the pathologist to demonstrate these
changes. In such instances the rickettsiae
of spotted fever are fewer and larger. Con-
siderable experience is required for such
differentiation.

The pathologic changes induced by the
two organisms are essentially the same,
being described as an acute endangiitis of
the small blood vessels throughout the body,
particularly in the brain and skin. There

is, however, in Rocky Mountain spotted
fever usually a more severe lesion in the
vessels and a greater enlargement of the
spleen as compared to typhus, as well as a
greater tendency to gangrene. In spotted
fever, the rickettsiae invade the smooth
muscles of the media of the blood vessels,
in typhus the endothelium. Hence, throm-
botic lesions in spotted fever are generally
more severe than in typhus fever, and
necrosis of fingers, toes, face, ears, scrotum
and vulva may occur.

The clinical picture of Rocky Mountain
spotted fever is remarkably similar to that
of endemic (murine) typhus commonly
seen in this locality. Perhaps the most out-
standing clinical difference is the character
of the rash. The rash of spotted fever ap-
pears earlier in the illness, often within 24
to 48 hours after the onset, than that of
typhus fever, and is usually more hemorr-
hagic and purpuric in nature. At times a
macular, rose-colored eruption may precede

it. The rash of spotted fever tends to ap-
pear first on the back, wrist and ankles,'
with early involvement of the palms of the
hands and soles of the feet. Later the fore-
head, arms, legs, cnest and abdomen are af-
fected. The spread takes two to three days.
In endemic typhus the rash usually appears
first on the chest and upper abdomen, and
involvement of the face, wrists, ankles,
palms and soles rarely occurs. Both the
rash and other clinical features of the two
diseases in individual patients may be so
varied that clinical differentiation by these

means usually is fraught with difficulty.
Neither the nature of the lesions nor their
localization can be relied on absolutely for
differentiation. Moreover, the exanthem
of the two diseases may be confused readily
with those seen in sulfonamide dermatitis,
streptococcic septicemia, cerebrospinal spot-
ted fever, measles and toxoplasmosis.

When Rocky Mountain spotted fever was
believed to be confined to the western Unit-
ed States, geographic distribution was used
to differentiate these diseases. However,
demonstration that these diseases may both
be present in many parts of the world, in-
cluding the south and southeastern United
States, has removed geography as a dif-
ferential diagnostic tool. Clinical charac-
teristics which are commonly given as dif-
ferential points often fall down because of
the variability of the clinical picture. His-
tory of tick bite when obtained is helpful.
The time of onset and distribution of the
rash has already been mentioned. Length
of febrile course is another feature. In the
Gulf states, typhus fever commonly runs a
14 or 16 day febrile course, but we have oc-
casionally seen patients febrile for 19-20
days, a period more common in spotted
fever. Brain lesions occur in both and the
scrotal reaction may also.

Definite differentiation of Rocky Moun-
tain spotted fever and typhus fever was
first shown in 1910 in cross-immunity ex-
periments by Ricketts and Wilder. The dif-
ferentiation must still be effected chiefly by
laboratory means. Of first importance in
the diagnosis of either disease is the Weil-
Felix reaction. In general, agglutinins in
spotted fever are usually in low titer for all
three strains of Bacillus proteus, whereas
the principal agglutinins for typhus fever
are for OX-19. In the mild strains of both
diseases with which we deal in the Gulf
states these criteria are often unreliable as
we have observed in two instances occur-
ring in Louisiana but not herein reported.
Hence differentiation by the Weil-Felix re-
action alone should not be made. The lowest
titer of diagnostic importance is 1:160, but
a rising titer during the course of the dis-
ease is of even greater significance. Agglu-

Pullen, Sodeman and Felknor — Rocky Mt. Spotted Fever

361

tinins are usually present by the end of the
first week but may not appear until con-
valescence. Repeated observations should,
therefore, be made.

In experienced hands, biopsies of the skin
are valuable diagnostic procedures. A
clearly demarcated, macular lesion should
be excised widely, fixed in Regaud’s fluid,
and stained by the Giemsa method.3 In ty-
phus, rickettsiae will be found only in endo-
thelial cells, whereas in Rocky Mountain
spotted fever the rickettsiae will be found
in the smooth muscle cells of the arteriolar
walls. This finding is diagnostic but rick-
ettsiae are not always found in the speci-
men.

In doubtful cases, inoculation of male
guinea pigs and male white rats may be
necessary. Here cross immunity tests may
be done. Three to 6 c. c., preferably the
latter, of blood drawn from the patient dur-
ing the first week of the disease is injected
intraperitoneally into each of several guinea
pigs and rats. An incubation period of
four to twelve days should elapse. The
febrile course is watched. Scrotal reactions
in either animal with the development of a
heavy exudate with abundance of rick-
ettsiae are typical of endemic typhus. In the
rat it is conclusive. As stated in an earlier
paragraph concerning etiology, smears of
scrotal cells in typhus reveal massive
growth of the rickettsiae in the cytoplasm
with no invasion of the nuclei. In Rocky
Mountain spotted fever in the scrotal reac-
tion, such smears reveal few, large, widely
disseminated rickettsiae in the cytoplasm.
If the animals do not react sufficiently,
cross immunity tests with known strains of
typhus fever and spotted fever will usually
complete the diagnosis. In some mild
atypical strains, the results of these tests
may not be decisive. Here, tissue cultures
may be helpful; the extensive intranuclear
growth in spotted fever is clearly seen,
while the typhus organisms grow extensive-
ly in the cytoplasm.

In instances in which the blood was taken
too late in the disease (after the sixth day),
or the animal inoculations fail, protection
tests may be carried out. The serum from

a convalescent patient is infected with
known strains of typhus fever and Rocky
Mountain spotted fever and injected intra-
peritoneally into guinea pigs, using con-
trols. If immunity to either disease has de-
veloped in the convalescent patient, the
guinea pig inoculated with that particular
virus will be protected from severe reac-
tion.

Since animal experimentation does not
lend itself well to clinical practice, other
simpler methods are desirable. Bengtson
and Topping4 have recently devised a spe-
cific complement fixation test for the recog-
nition of typhus fever, the antigen consist-
ing of rickettsiae grown in the yolk sac of
chick embryos. A similar complement fix-
ation test for Rocky Mountain spotted fever
has been reported by Plotz and Wertman.5
In a personal communication to the authors,
Bengtson'1 stated that cross reactions had
been noted between the strains of Rocky
Mountain spotted fever and endemic (mu-
rine) typhus of the South. More work is
needed to clarify this point.

The following case report of Rocky Moun-
tain spotted fever will depict the clinical
picture and emphasize its similarity to that
of endemic (murine) typhus fever.

CASE REPORT

J. M., a 50 year old, white male, an inmate of
the State Penitentiary at Angola, Louisiana, was
referred to Charity Hospital on August 1, 1944,
complaining of symptoms of two weeks’ duration,
during which time he had chills and fever up to
104°F., profuse sweating, malaise, muscle and
joint pains, cough, pain in the epigastrium and
chest pain which was aggravated by inspiration.
He is believed to have been delirious for a large
portion of that time. The patient had been per-
mitted to do outdoor work at the penitentiary such
as working in the pumping station previous to this
illness. On admission, his temperature was 100.4°
F., pulse 102, respirations 30 per minute, blood
pressure was 115/80. He appeared weak, exhaust-
ed and acutely ill, but his sensorium was clear.
Examination of the skin revealed small vesicles
and purplish, erythematous lesions on the posterior
and lateral aspects of the neck, abdomen and ex-
tremities. These lesions were not numerous or
confluent. Petechiae on the lower extremities were
numerous. No lymphadenopathy could be demon-
strated. The remainder of the physical examina-
tion revealed no deviations from normal, that is,
there were no evidences of bronchitis, splenic en-

362

Hauser — Food Poisoning

largement, dicrotic pulse, cardiac gallop rhythm,
or nervous system finding's such as may occasion-
ally be seen in acute infectious diseases. A Rum-
pel-Leede’s test was negative. The hematologic
study revealed 10 gm. of hemoglobin (Sahli), 3,-
050,000 red cells, 4,250 white blood cells, and 83,725
platelets. The differential count disclosed 54 per
cent polymorphonuclear leukocytes, 32 per cent
lymphocytes, 10 per cent immature cells, and 4 per
cent monocytes. No malarial parasites were found.
Urinalysis was normal, as were blood chemical
studies. Kline and Kolmer tests were weakly posi-
tive. Three consecutive blood cultures on alter-
nate days were negative. Cultures and smears of
the stools were negative for any pathogenic or-
ganisms. Agglutinations of serum on August 4,
three days after admission, were negative for E.
typhi, paratyphi B, Br. melitensis, Br. abortus, and
B. proteus X-19. These were repeated on August
7, and were found positive for B. proteus X-19 in
1 :320 dilution.

The patient’s condition in the hospital improved
steadily. Therapy consisted entirely of supportive
and symptomatic measures. For the first seven
days, he manifested an intermittent, daily, after-
noon rise of temperature to 100.8° F. which sub-
sided at the end of the first week in the hospital
(at the end of the third week of illness). His
pulse did not rise above 100 at any time through-
out his hospital course. The rash faded gradually
and on August 14, it was no longer discernible.
He remained afebrile for two subsequent weeks of
hospitalization, improved rapidly in strength and
well-being, and was discharged on August 21, 1944.

On the day of discharge from the hospital, sam-
ples of his blood were forwarded to the National
Institute of Health, Bethesda, Maryland, for fur-
ther study. Complement fixation test was posi-
tive for Rocky Mountain spotted fever in a dilu-
tion of 1:2048. There was a slight fixation (1-|-)
for endemic typhus in dilutions 1:4 to 1:512.
This was interpreted as negative. Agglutination
tests were positive in a dilution of 1:1280 to B.
proteus X-19, and negative for B. tularense, Br.
abortus, B. typhosus, and B. paratyphosus A and
B, B. clysenteriae Shiga, B. dysenteriae Flexner,
Leptospira icteroheuiorrhagiae (Weil’s disease)
and Leptospira , canicola.

SUMMARY

A report of the first case of Rocky Moun-
tain spotted fever diagnosed at the Charity
Hospital has been presented. In the in-
dividual patient, the clinical picture is in-
distinguishable from that commonly seen in
endemic (murine) typhus fever, hence the
diagnosis must be based on laboratory evi-
dence as the specific complement fixation
test, skin biopsies, animal inoculations and
cross immunity tests, and protection tests.

In certain cases, the diagnosis becomes ex-
ceedingly difficult and requires technical
skill not readily available in most communi-
ties. If Rocky Mountain spotted fever is
considered in the differential diagnosis of
all acute infectious diseases, particularly
those with exanthematous manifestations,
and specimens of blood sent to diagnostic
centers for study, it is not unlikely that
more instances of this disease will be found.

references

1. Badger, L. F., Dyer, R. E„ and Rumreich, A. : An
infection of the Rocky Mountain spotted fever type, iden-
tification in the Eastern part of the United States, Pub.
Health Rep., 46 :463, 1031.

2. Anigstem, L., and Bader, M. N. : Investigations - on
rickettsial diseases in Texas, Texas Rep. Biol. & Med.,
1 :117, 1043.

3. Pinkerton. II.: Spotted Fever. In Bercovitz. Z. T. :
Clinical Tropical Medicine, New York City, Paul B. Iloe-
ber. 1944.

4. Bengtson. I. A., and Topping. N. II. : The specificity
of the complement fixation test in endemic typhus fever
using a rickettsial antigen, Pub. Health Rep., 56:1723,
1941.

5. riotz, II.. and Wertman, K. : The use of the comple-
ment fixation test in Rocky Mountain spotted fever, Sci-
ence, 95 :441, 1942.

6. Bengtson, I. A. : Personal communication to the au-
thors.

O

FOOD POISONING*

GEORGE H. HAUSER, M.D.f
New Orleans

The term food poisoning is used to de-
scribe an acute gastroenteritis following the
eating of contaminated food. Outbreaks
may involve anywhere from a few to a
hundred or more victims. Many small out-
breaks of slight severity go unreported, or
are improperly diagnosed ptomaine poison-
ing. This is a misnomer introduced by
Selmi,3 the Italian toxicologist, in 1870. It
is taken from the word “ptoma” which
means corpse. Ptomaines, ammonia sub-
stitution compounds, are simply the result
of decomposition of the protein molecule
and are produced by any bacteria which can
bring about this degree of proteolysis. A

*Read before the sixty-fifth annual meeting of
the Louisiana State Medical Society in New Or-
leans, April 24-26, 1944.

IFrom the Division of Laboratories, Department
of Health, State of Louisiana and City of New
Orleans, Central Laboratory.

Hauser — Food Poisoning

363

few of the ptomaines are physiologically ac-
tive. If injected parenterally, some are
poisonous. Administered orally, even in
relatively large amounts, the more poison-
ous ones are not toxic nor do they produce
gastrointestinal symptoms.8

There is a popular tendency to associate
food poisoning with putrefaction. It is
known that putrefaction of a food does not
give rise to toxic substances involved in
food poisoning. There are some wholesome
foods dependent upon putrefactive bacteria
for their flavor and taste, such as limberger
cheese, and the process involved may be
considered essentially commercially con-
trolled putrefaction. However, even in
such products, food poisoning bacteria or
chemicals may be present and produce typ-
ical symptoms of specific gastroenteritis.
When large numbers of persons are af-
fected, particularly if they have attended a
banquet or eaten in some public establish-
ment, considerable publicity is often given
the episode by the press and thorough in-
vestigation is made by public health author-
ities. '

The causes of food poisoning may be di-
vided into three groups: (1) chemicals and
drugs; (2) poisonous plants and animals;
(3) bacteria and their products.3 Individ-
ual food idiosyncracy might be added to this
classification for clinical purposes.

Gastrointestinal upsets may be due to
such chemical poisons as antimony, arsenic,
lead, cadmium, fluoride {especially sodium
fluoride), methyl chloride, mercury, zinc,
and many others. Chemical poisons have
often been mistaken for medicine, baking
powder and starch. An example of this re-
cently occurred in one of our large state
institutions. One night 14 inmates became
desperately ill, one of them dying. Food
poisoning was immediately suspected be-
cause of the explosive character of the out-
break, and many samples of food found in
the kitchen were submitted for examina-
tion. Within a few hours, sodium fluoride
was found in one of the biscuits. The stom-
ach of the dead woman contained the same
poison. Samples of white powder in an
unlabelled jar were found to be roach poi-

son containing sodium fluoride. Imme-
diately upon obtaining this information, the
physican at the institution was notified.
Subsequent investigation revealed that a
new cook, during preparation of her first
meal, mistook the roach poison for baking
powder and used it in the biscuits. Many
smilar examples might be cited.

Cases due to poisonous plants and animals
include shellfish, mushroom, milk sickness
or snake-root poisoning, ergotism, water
hemlock poisoning and the like.

Since cases of food poisoning due to bac-
teria or their products are the most com-
mon, the organisms responsible for such
cases and their effect upon man will be
more fully discussed.

There are four types of bacteria definite-
ly known to cause food poisoning in man,
namely: staphylococci, Salmonella, C. botu-
linum, and streptococci.13 Outbreaks have
been reported due to Bacterium coli and the
Proteus group, but proof that these micro-
organisms are the causative agent is incon-
clusive.

STAPHYLOCOCCI

Staphylococci are responsible for 90 per
cent of the outbreaks. This organism is
widespread in nature and found normally
in the nose, throat, and skin of healthy in-
dividuals, but not all are capable of produc-
ing food poisoning. Only those strains
capable of producing enterotoxic substances
when grown in suitable medium are the of-
fenders— strains of S. aureus and occasion-
ally S. albus.

The findings of these organisms in the
incriminated food or vomitus raises the
question of a possible etiologic agent, but
does not establish a diagnosis. The isolated
strains must be proved to be capable of
producing enterotoxin.

There are few satisfactory criteria, at
the present time, for the differentiation of
the enterotoxin and non-enterotoxin produc-
ing strains. Stone10 has claimed that food-
poisoning strains could be distinguished by
the liquefaction of a special gelatin medium.
Chapman, Leib, and Crucio2 suggested the
use of certain in vitro reactions for the iden-
tification of food-posoning strains, such as

364

Hauser — Food Poisoning

hemolysin production, mannitol fermenta-
tion, growth on brom-thymol blue agar,
liquefaction of gelatin by Stone’s method,
and the coagulation of human and rabbit
plasma. Positive results in all these were
considered presumptive evidence. However,
there seems to be no evidnce of homogeneity
in strains studied by many laboratory
workers. In a number of outbreaks studied
by Stone,11 83.5 per cent produced pigment,
77.1 per cent were hemolytic, 88.0 per cent
produced a characteristic reaction on
Stone’s gelatin agar, 74.2 per cent coagu-
lated plasma, and 93.6 per cent fermented
mannite.

The most reliable method of testing the
production of enterotoxin by staphylococci
is the feeding or injecton of the filtrate into
experimental animals. In earlier studies, it
was necessary to feed filtrates to human
volunteers. This is hazardous and unreli-
able, and as a routine laboratory test, im-
possible. Monkeys ha\*e also been used,
but obtaining and handling are difficult,
and experimental work done by Dack,
Shaughnessy and Grubb'1 has shown that
they do not react consistently to the toxic
filtrate. Results obtained from the use of
small laboratory animals are not very satis-
factory. Dolman1 and his coworkers have
found that filtrates injected intraperi-
toneally produce a typical syndrome in six
to eight week old kittens weighing 350 to
550 grams. The intravenous injection of
filtrates into adult cats has also been satis-
factory.

The enterotoxin type of staphylococcus
food poisoning is characterized by symp-
toms of nausea, vomiting, diarrhea, and
acute prostration within a half to six hours
after eating. The morbidity rate is usually
very high, with 75 to 100 per cent of the
persons who eat the food being attacked.
The patient appears acutely ill and symp-
toms are severe while they last, but recov-
ery is rapid and usually complete within
48 hours.

SALMONELLA

The next most common type is Salmonella
food poisoning. This type is often referred
to as the “infection type” and is due to the

multiplication within the body of patho-
genic bacteria present in food. Those most
frequently isolated are S. typhi murium and
S. enteritidis, but many other species of the
group have been identified as the causative
agent in outbreaks all over the world. Sal-
monella food poisoning is apparently more
prevalent in Europe than in North America.
Unlike staphylococcus food poisoning, the
bacillus does not produce a toxin, but the
bacteria themselves produce the infection.

The isolation and identification of strains
of Salmonella organisms by biochemic and
serologic means from food, excreta, and
vomitus, and the finding of agglutinins in
the blood of patients after infection gen-
erally establishes the etiologic agent. It is
not necessary to resort to animal inocula-
tion.

In this type of food poisoning, symptoms
generally appear in 10 to 12 hours and are
nausea, vomiting, diarrhea, prostration, ab-
dominal pain and fever. The morbidity
rate is high, but the case fatality rate low.
The patient is usually ill for a longer period
of time than in cases of staphylococcus food
poisoning.

BOX l' LIN I'M

The most fatal type of food poisoning is
due to Clostridium botidinus. This or-
ganism is an anaerobic spore-bearing ba-
cillus, capable of producing a highly po-
tent toxin, is very heat resistant and likely
to be present in canned food, especially
home canned products. However, the toxin
may be destroyed by heating to 80 °C. for
30 minutes. Contaminated cans are usually
puffed and the food shows evidence of de-
composition ; whereas with organisms of the
staphylococcus and Salmonella groups,
there is no change in appearance, taste or
odor.

Toxin produced by this organism gives
rise to clinically severe disease which is
often fatal and gastrointestinal symptoms
may occur early in the disease. It is a neu-
rotoxin and produces characteristic symp-
toms such as double vision, difficulty in
swallowing, and finally paralysis of the
pharyngeal muscles. The incubation period
ranges from a few hours to a few days. The

Hauser — Food Poisoning

365

case fatality rate is high, depending upon
the amount of toxin ingested.

STREPTOCOCCI

Streptococcus viridans has been proved to
be the cause of several food-poisoning out-
breaks. The organism does not produce a
toxin, but, likes the Salmonella group, pro-
duces infection.

The incubation period is from five to 18
hours and symptoms are abdominal pain,
nausea, vomiting, diarrhea, and prostration.
There are no reported fatalities from this
type of food poisoning.

The causes of gastroenteritis are numer-
ous, and not all cases characterized by sud-
den onset of intense nausea, vomiting, and
diarrhea are food poisoning. Certain in-
fections are characterized by nausea and
vomiting, and frequently require differen-
tial diagnosis from food poisoning. Out-
breaks of this type are often explosive in
nature and the first impulse on the part
of the public is to blame milk, water or some
food. They are, however, easily disting-
uishable from food-poisoning outbreaks, as
new cases arise from day to day, and fre-
quently infants on diets of boiled water and
milk are attacked. In a recent epidemic of
this type practically every type of food sent
to the laboratory for examination revealed
no etiologic agent. It is believed that such
epidemics are due to a virus and that spread
of the disease is by way of the respiratory
tract.

It is of prime importance that as soon
as food poisoning is suspected, health au-
thorities be immediately notified so that
investigation to determine the cause may
begin. Delay may result in contamination
or disposal of the remaining food. If all
the food has been consumed or discarded,
it is necessary to obtain vomitus, excreta,
or both from the affected individuals. In
the infection type, samples of blood may be
collected later, as the presence of agglu-
tinins is considered evidence of infection.
However, this does not give absolute proof,
for agglutinins may be present in the blood
as a result of previous infection.

The Division of Laboratories of the De-
partment of Health, State of Louisiana and

City of New Orleans, had the opportunity
to study outbreaks of gastroenteritis, many
of which proved to be due to food poisoning.
Several of the major outbreaks due to bac-
teria which occurred in 1942 and 1943 are
of interest.

On January 1, 1942, a large family group
ate dinner in a private home and all but
seven of them became ill with symptoms of
acute gastroenteritis from one to five hours
after the meal. They were taken to a hos-
pital where a tentative diagnosis of food
poisoning was made. The following morn-
ing the Health Department was notified of
the outbreak and investigation begun.

It was learned that the dinner had been
a community affair, each member prepar-
ing a dish and bringing it to the gathering.
Samples of the food remaining, chicken
salad, gumbo, turkey, cranberries, pumpkin
and apple pie, were collected and brought to
the laboratory for examination. Epidemio-
logic investigation revealed that all of the
persons who were ill had eaten the chicken
salad. It had been prepared in the morning
and was allowed to remain at room temper-
ature until consumed that evening.

Staphylococcus was found to be abun-
dantly present in the samples of the chicken
salad. Further laboratory procedures
proved them capable of producing an en-
terotoxic substance and therefore the cau-
sative agent in the outbreak. All the other
foods were negative for organisms of the
food-posoning group.

On March 23, 1942, an outbreak of gas-
troenteritis, suggestive of food poisoning,
was reported to the Iberia Parish Health
Unit, New Iberia, Louisiana. At the time,
13 persons were ill, all suffering from gas-
troenteritis with varying degrees of sever-
ity. Most of the patients were too ill to
discuss the possible source of infection, but
information gathered from relatives and
friends revealed that all of them had eaten
pork sausage.

The State Health Department was noti-
fied and the epidemiologist and others went
to New Iberia to conduct an investigation.
On March 21, 1942, a resident of New Ibe-
ria had received a package of unrefrig-

366

Hauser — Food Poisoning

erated pork sausage from a friend in Texas.
About two pounds of the sausage were
given to a friend and some of it taken to
a nearby restaurant where it was fried
and served to a party of five. Later the
proprietor broiled a small portion of the
sausage and ate it. The two pounds given
to a friend were fried by his wife and eaten
by them for supper. The remaining portion
was prepared in the form of a loaf and
served to a family of six the following day.

All the persons who ate the sausage, with
the exception of the proprietor of the res-
taurant, became ill four to 24 hours later.
They all had similar symptoms, nausea,
abdominal pain, diarrhea, chills and fever.
The acute symptoms subsided in three to
five days and all recovered.

The remaining uncooked sausage was
sent to the laboratory for bacteriologic ex-
amination and an organism belonging to
the Salmonella group was isolated. A cul-
ture of the organism was sent to the U. S.
Salmonella Institute at the University of
Kentucky for confirmation and classified
as S. berta.

Stool specimens were collected from the
patients during the acute stage of the dis-
ease. S. berta, the same organism isolated
from the sausage, was recovered from eight
of the stool specimens collected. To com-
plete the investigation, samples of blood
were collected from the patients about one
month after the outbreak. Four samples
were collected and of these, three showed
the presence of specific agglutinins of
S. berta.

The isolation of S. berta from the sausage
and feces is most interesting, since this or-
ganism previously had not been reported
in the United States. It was originally
isolated by Hormaeche and Salsamendi7
from the mesenteric lymph glands of nor-
mal hogs in Montevideo, Uruguay.

On March 24, 1942, an outbreak of food
poisoning occurred in New Iberia, involv-
ing nine persons who had eaten home made
ice cream. All became ill, with chills, fever,
nausea, vomiting, and diarrhea, which per-
sisted for several days. The majority had
very watery stools with a noticeable

amount of blood. None of the ice cream
was available for bacteriologic examina-
tion, but Salmonella ty phi murium was iso-
lated from specimens of stool from all the
cases.

On Sunday. April 26, 1942, a large group
of residents in the Metairie area became
acutely ill, with symptoms suggestive of
food poisoning. Many of them were treated
at hospitals while others were treated at
home. Investigation revealed that all of
the victims had eaten confections prepared
at the same bakery. The following morn-
ing, samples of the confections were col-
lected from the homes of several of the vic-
tims and from the bakery, and submitted
for examination. They consisted of jelly
doughnuts, cream-filled doughnuts, round
doughnuts, breakfast cakes, cream puffs,
lemon meringue pie, chocolate cream pie,
vanilla cream pie, quart bottles of milk,
meringue mix, a bag of corn starch, and a
bag of powdered sugar.

Cultural examination revealed hemolytic
Staphylococcus aureus in abundance in the
specimens of cream doughnuts collected
from the houses of several of the victims
and from the bakery, and in the cream puffs
obtained from the bakery. Cultural and
animal studies confirmed these organisms
as belonging to the food-poisoning group.
All of the other confections were negative
for such organisms.

A thorough inspection of the bakery was
made by the Jefferson Parish Health Unit.
The employees of the bakery were exam-
ined, and nose, throat and skin cultures
taken. A culture from a furuncle of the
finger of one of the employees showed
Staphylococcus aureus of the food-poison
ing type.

On July 28, 1943. an outbreak of food
poisoning similar to the Jefferson outbreak
occurred in New Orleans. It was caused by
contamination of cream-filled pies with
hemolytic Staphylococcus aureus of the
food-poisoning type. Examination of nose
and throat cultures, and culture from pus-
tular lesions of several employees were
made. Culture from a lesion on the wrist

Hauser — Food Poisoning

367

of one of the employees showed the pres-
ence of hemolytic Staphylococcus aureus.

The type of food causing an outbreak
must be taken into consideration, since work
on the epidemiology of food poisoning shows
that certain foods may be considered “vul-
nerable” to contamination. Infection may
come from: (1) the animal itself; if the
animal is so contaminated, the whole car-
cass may be infected, in which case there
will be widespread incidence of food poison-
ing; (2) from food handlers who are car-
riers, or (3) from fouling by vermin such
as rats and mice of food improperly stored.1

In Salmonella infection, fresh meat, milk
and milk products, fish, poultry, and made-
up dishes are the commonest vehicles of in-
fection.9 The foods associated with staphy-
lococci outbreaks are usually meat or meat
products, milk products, more especially
cream or custard filled pastries.12 Botu-
lism generally results from home canned
foods. Stone reports that of 96 outbreaks
in which the enterotoxin producing staphy-
lococci were involved, 43 per cent were due
to cream or custard filled pastry, 35 per
cent meat and products of meat, 19 per
cent to dairy products, 2 per cent to pota-
to salad, and 1 per cent to moldy syrup.11

The method used in introducing custard
into eclairs, pies or cake confections may
be responsible for the prominence of this
group as a cause. The operator uses a can-
vas pastry bag which is intimately handled
and he may have an infection on his hands,
or the bag may not have been properly ster-
ilized before use. The cream-filled pas-
tries are then allowed to remain at room
temperature where bacterial multiplication
and toxin production occur. Immediate
consumption of cream-filled pastries or re-
frigeration of such foods at a temperature
that inhibits growth is recommended. Gil-
creas and Coleman5 have shown that rebak-
ing of cream-filled pastries after filling at
216 CF. for fifteen minutes will destroy any
organisms without materially affecting the
pastry. Others have added harmless chemi-
cals which inhibit bacterial growth without
altering the taste. Many bakeries restrict

the preparation of cream-filled pastries to
the winter months.

Food which, when prepared and con-
sumed immediately, is satisfactory, but may
upon standing at room temperature become
harmful. In many outbreaks the food sold
shortly after manufacture causes no illness,
while that sold after standing several hours
at room temperature causes severe attacks
of food poisoning. In other cases, food
manipulated during preparation or handled
subsequently has allowed organisms to gain
access and multiply. Many restaurant pro-
prietors have found it cheaper to destroy
perishable foods not consumed at one meal
than to take the chance of holding them
over for another meal. This is especially
true of meats and made-up dishes that re-
quire handling.

As the war continues, the problem of bac-
terial food poisoning is likely to increase as
a result of food shortages and food ration-
ing. As a consequence of food scarcity,
edibles will be made to last over a period of
time and the serving of left-over foods will
become common. Unless refrigeration and
good sanitation are scrupulously observed,
many of these foods will become contami-
nated and dangerous for human consump-
tion. Lack of canned foods and shortages
of food are bound to lead to a revival of
home canning, with the almost inevitable
result of cases of botulism.

Every effort must be made to keep food
clean ; this is no time to stop our insistence
that “cleanliness is next to godliness.” Our
principal safeguards are the elimination of
infected food handlers, proper refrigeration
of perishable foods, enforcement of public
health regulations and constant and effic-
ient laboratory control.

SUMMARY

1. Food poisoning outbreaks are a com-
mon occurrence throughout the state.

2. A variety of causes are responsible
for these outbreaks.

3. Bacteria are the most frequent cause,
the enterotoxic type of staphylococci most
commonly implicated.

4. The cases present a typical history and
clinical syndrome.

368

Hauser — Food Poisoning

5. Summary of some of the outbreaks in
the state during 1942-43 are presented.

6. Foods most commonly concerned in
such outbreaks are listed.

7. History of period of incubation at
room temperature between preparation and
consumption of food is usually noted in
toxic types.

8. Rebaking or the addition of substance
to inhibit bacterial growth are of value in
staphylococcus type.

9. Elimination of infected food handlers,
proper preparation and refrigeration of
food, and careful sanitation are necessary
to prevent outbreaks of food poisoning.

REFERENCES

1. Burnfortl, Julius: Food poisoning, Brit. M. J.. 4028:
018, 1938.

2. Chapman, G. II., Leib, C. W., and Crucio, L. G. :
Isolation and cultural differentiation of food poisoning
staphylococci, Food Research, 2 :349, 1937.

3. Dack, G. M. : Food Poisoning, University of Chicago
Press, 1943.

4. Dolman, €. E., Wilson, R. J., and Crockcroft, W. H. :
New methods of detecting staphylococcus enterotoxin, J.
Public Health, 27:489, 1936.

5. Gilcreas, F. W., and Coleman. M. B. : Studies of re-
baking cream-filled pastries, Am. .T. Public Health, 31 :
956, 1941.

6. Grubb, Thomas C. : The present status of the staphy-
lococcus food poisoning problem, .1. Lab. & Chem. Med.,
23:1150, 1938.

7. I-Iormaeche, C. A., and Salsemendi, R. : Sobre la

presencia de Salmonellas en los ganglios mesentericos de
cerdus normanes, Arch. Uruguay de Med. Cirug. y Esp.,
9 :665, 1936.

8. Lyons, G. M. : Food contamination and poisons, .T.
Pediatrics, 21 :392, 1942.

9. Savage, AV. G. : Some problems of salmonella food
poisoning, (Tenth Wm. Thomas Dedgewich Memorial Lec-
ture) J. Preventive Med., 6 :425, 1932.

10'. Stone, R. V. : A cultural method for classifying
staphylococci of “food poisoning’’ type, Proc. Soc. Ex-
perimental Biol. Med., 33 : 185, 1935.

11. Stone, I!. V. : The epidemiology of staphylococcus
(food poisoning, read at meeting of A.P.H.A. Detroit, Oct.
9, 1940.

12. Tanner, F. W. : Food-Borne Infections and Intoxi-
cations, Twin Cities Printing Co., Champagne, III., 1933.

13. Topley, Wilson: Text Book of Bacteriology, Williams
& Wilkins Co., Baltimore, 1941.

DISCUSSION

Dr. Waldo L. Treuting (New Orleans) : I can
add very little to Dr. Hauser’s presentation but I
would like to stress some of the more important
points. First, food poisoning is a very common dis-
ease, probably as common as the common cold.
Very few individuals go through a lifetime with-
out experiencing one or more outbreaks of this
type of illness. The vast majority of outbreaks
are small and limited primarily to members of one
household. This type does not come to the atten-
tion of health authorities and usually is not in-
vestigated as to cause. The larger outbreaks in-
volving many people who have attended a public

gathering or who have purchased contaminated
food from a single place, are reported to the health
department and from these statistics the causes
are gathered. Bacterial food poisoning, as brought
out by Dr. Hauser, is by far the most common and
most important type and staphylococcus is the
most frequent offender. Isolation of staphylococcus
from the suspected food is but presumptive evi-
dence and not proof of its causal relationship.
However, since it has been demonstrated that
staphylococcus toxin is capable of producing symp-
toms of food poisoning, the finding of this organ-
ism in suspected food is accepted as sufficient
evidence for its incrimination.

In the Salmonella or infection type, the next
most common type, the proof of causal relation-
ship is more definite. Isolation of Salmonella from
excreta and vomitus and detection of agglutinins
in the blood is positive proof of causal relationship.

Dr. Hauser mentioned Bacterium coli and mem-
bers of the Proteus group as being the causes of
outbreaks. The streptococcus has only been proved
recently to cause outbreaks. Possibly there are
many other bacteria not at present incriminated
that may also cause food poisoning.

It is well worth stressing the types of food us-
ually responsible for outbreaks. Dr. Hauser men-
tioned meat and meat products, and milk and milk
products usually the vehicles in the Salmonella
type; milk and milk products, particularly cream,
fried pastries such as cream puffs, and salad
dressings are most frequently associated with the
stayphylococcus type.

From each outbreak a lesson should be learned.
Progress has been made in educating food handlers
and operators of food handling places. In the edu-
cation of the general public to the proper handling
of food, the surface has not been scratched. This
is most important at the present time.

Dr. Clyde Brooks (New Orleans) : We are very
much indebted to Dr. Hauser for his very inter-
esting paper. However, there is one type of poison-
ing which he did not mention, which probably oc-
curs more often than we suspect, and that is
poisoning by molds such as molded bread. The
literature yields numerous instances where poison-
ing occurred and where there is strong presump-
tive evidence that the poisoning was due to mold,
however there appears to be reluctance on the part
of physicians as well as bacteriologists to accept
the evidence that molds had caused poisoning. I
am inclined to the opinion that molds do cause
poisoning and that this reluctance to accept these
findings is because there are very few “moldolo-
gists” (mycologists) whereas there are many bac-
teriologists.

Dr. C. C. deGravelles (New Iberia) : We are
speaking about food poisoning but I want to divert
a little from the subject and ask Dr. Hauser a
question about a type of poison I think should be

Hauser — Food Poisoning

369

interesting' to all of us at the present time. I do
not know about the customs in most parts of
the country but in my section there has been a
custom for many years, among old folks and grand-
mas, to give a teaspoonful of gunpowder when
someone had a fall. Some of them have gotten
away from it but there is still some used.

Last Saturday morning I had an urgent call
from a man whom they said was dying. I reached
there and thought he was dying. I stayed with
him about five hours and he got all right. I in-
quired about his illness. He was a man about 58
years old who had had a bad fall and had bruised
his back. His mother gave him gunpowder and
he became very ill. When I saw him he was in a
state of collapse; no pulse, cyanosed, and critically
ill. I washed his stomach out and continued to
wash it out and in three or four hours he came
back and made an uneventful recovery. He said
w'hen he came to — “I didn’t want to take that
gunpowder; it had white spots in it. The kind we
used to take was black.” I believe if this new gun-
powder we’re making has this in it we should tell
the old aunties and grandmas to keep off of gun-
powder. I would like to ask Dr. Hauser about the
type of chemical in the new gunpowder.

Dr. John R. Schenken (New Orleans) : I would
like to ask Dr. Hauser what is the result of the
agglutination tests in the Salmonella group. It has
been our experience in many cases that these
people do not develop any measurable agglutinin
titer. I do not know why. The diagnosis in most
cases must rest on isolation of organism from food
or people ill rather than on presence of agglutin-
ins in the blood.

Dr. George Hauser (in closing) : Dr. DeGra-
velles has discussed a very interesting custom
which exists in some parts of Louisiana. For many
years gunpowder has been given as a home remedy
in case of injuries, apparently with no bad effect
until of late. We are all familiar with the old
form of gunpowder known as black powder, which
when exploded produced a large amount of black
smoke, frequently obscuring the aim of the good
hunter. This has been superseded to a great ex-
tent by the so-called smokeless powders and I be-
lieve it is these powders which contain the white
spots as mentioned. It is my belief that the black
powder contains no nitroglycerine whereas the

smokeless powders do, which accounts for the
episode of collapse.

Dr. Schenken has asked about the use of agglu-
tination tests in making a diagnosis of Salmonella
infection. The value of this method is frequently
not satisfactory because: (1) The agglutinin re-
sponse in infected persons is generally poor and
(2) agglutinins to organisms of the Salmonella
group are not infrequently found in sera of healthy
persons. In patients who have had previous en-
teric infection or in those who have received ty-
phoid vaccine, the titer is often high. For this rea-
son, if diagnosis is to be made on agglutination
tests, it is necessary to secure a sample of blood
eai'ly in the disease and to repeat the test in about
ten days. Unless a considerable increase in titer
occurs, no conclusion as to type of infection can
be made. The isolation of the organism from the
food, feces, vomitus or necropsy material is much
more satisfactory and reliable.

I am interested in Dr. Brook’s discussion. As he
mentioned, molds as a cause of food poisoning
have recently received a great deal of attention.
The simple presence of mold in food does not
mean that it will cause food poisoning as many
foods considered a delicacy contain molds of va-
rious types. In view of the fact that common
molds are frequently found in food or in food
which has become contaminated through improper
handling, great caution should be exercised before
designating molds as the etiologic agent in cases
of food poisoning. We have had no cases of food
poisoning due to molds. The doctor mentioned
certain cases in which animals ate molded food
and became ill. There are certain weeds that pro-
duce food poisoning in some animals, such as milk
poisoning in cattle.

Great care must be exercised in the examination
of all cases of food poisoning. Too frequently, su-
perficial, inaccurate or incomplete examination
will fail to determine the causative agent. Modern
bacteriologic methods must be employed and a
thorough search made in an effort to determine
the etiologic agent.

Dr. Treuting has emphasized the frequency with
which cases of food poisoning occur. It should be
kept in mind that certain foods are more likely to
be incriminated in food poisoning and also that
great care must be exercised in collecting speci-
mens for bacteriologic examination.

370

Editorials

NEW ORLEANS

Medical and Surgical Journal

Established. l&UU

Published by the Louisiana State Medical Society
under the jurisdiction of the following named
Journal Committee:

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For two years: G. C. Anderson, M. D., Chairman
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For one year: J. K. Howies, M. D., Vice-Chairman
For three years: C. Grenes Cole, M. D., Secretary
E. L. Leckert, M. D.

EDITORIAL STAFF

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COLLABORATORS— COUNCILORS
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in duplicate when returning galley proof.

Manuscripts should be addressed to the Editor,
USO Tulane Avenue, New Orleans, La.

The Journal does not hold itself responsible for
statements made by any contributor.

THE PEPPER REPORT

The third Interim Report on “Wartime
Health and Education” has just been pub-
lished by the subcommittee of which Sena-
tor Claude Pepper of Florida is chairman.
This report is in goodly part factual but
at the same time it also makes certain rec-
ommendations which are summarized on
the basis of the preliminary finding of the
Subcommittee of the Committee on Educa-
tion and Labor of the United States Sen-
ate. The recommendations are too long to
incorporate in an editorial but they will be

printed in the organization section of the
Journal. As a matter of fact it would be
advisable for every doctor in the state to
obtain a copy of this report. Undoubtedly
it can be obtained either from one of our
two United States Senators or from one of
the State Congressmen. Representative
Hebert was good enough to send a copy to
the office of the Secretary of the State Med-
ical Society.

The reason that the report should be
read by members of our profession lies in
the fact that there are many data in the re-
port with which medical men are not fam-
iliar and that the summarized recommenda-
tions which are printed in the Journal are
based on the observations and studies of
this Committee which are entirely too long
to print in detail. Lastly the final recom-
mendation suggests that Federal funds be
made available to states for the medical
care of recipients of public assistance and
in the body of the report discusses how this
may be accomplished. This final recom-
mendation suggests to the Editor, if the
recommendation is adopted, that it will be
the foot in the door which may eventually
open wide that door to Federalized medi-
cine. However, this is merely an assump-
tion; as a matter of fact one gets the im-
pression that the Subcommittee is not in
favor of a generalized program of medical
care for all citizens which would be univer-
sal throughout the country.

To substantiate this last statement in the
last paragraph it might be noted that the
Committee calls attention to the fact that
it is the low income group that needs the
most medical care — “sickness and poverty
go together.” The Committee apparently
feels that some type of medical care should
be provided for the indigent and near in-
digent, the sixteen million families whose
total income is less than $2000 but not for
the somewhat over sixteen million families
whose income is above this level. They are
speaking now of families in the income
group and not of individuals nor of the
total population of the country. It is esti-
mated that there are slightly over thirty-
three million family groups in the country.

Editorials

371

The report further says that insurance
methods alone will not solve the problem of
the indigent because insurance methods are
not applicable to the unemployed or to those
in the low income group. It notes further-
more in this same paragraph that any
method that is offered should include com-
plete medical care. Most of the insurance
schemes that are in effect at the present
time have to do largely with illness that re-
quires surgical intervention. The Commit-
tee states that the medical care should not
be cut rate in cost and should permit the
free choice of physician or group of physic-
ians and should allow participation in policy
by all groups concerned, implying here that
the professional group would definitely
have representation on whatever Board or
Committee or Bureau would have over all
charge of the management of the funds that
are allotted to the care of the very low in-
come group.

Senator Pepper as well as the other four
Senators on this Committee suggest, as
their most objective recommendation, the
organization of a coordinated hospital serv-
ice plan. This plan would have, in the sec-
tions of the country which are not well sup-
plied with physicians, at least at the onset
of the introduction of the plan, a health cen-
ter in small communities. From this health
center would be fed to the nearest “rural
hospital,” patients who needed hospital care
to a limited extent, that is for short illness-
es, minor surgery, obstetrics and so on.
The next step would be more elaborately
equipped hospitals with specialized staffs
which would be known as “district hospi-
tals.” Here practically every type of med-
ical care would be available to the patient.
Patients who present diagnostic problems,
who require services of highly specialized
specialists and so on would in turn be sent
to what is referred to as the “base hospi-
tal.” The base hospitals should be in large
centers and should be units serving the en-
tire state. This hospital should be a teach-
ing hospital equipped for complete diag-
nostic service where it would be possible to
conduct extensive' postgraduate work and
research. Such a medical center should in-

clude also facilities for all types of institu-
tional care and for the care of chronic dis-
ease. The Committee obtained their infor-
mation concerning this set-up from the Sur-
geon General of the United States Public
Health Service.

To a somewhat limited extent in Louis-
iana, hospital service is provided for the in-
digent as it is in this coordinated hospital
service plan. Some of the smaller state hos-
pitals which have been organized for the
last few years are capable of taking care
of most all types of illness but many of
these patients who present special diagnos-
tic problems or require unusual types of
treatment are referred to the two big state
hospitals in Shreveport and New Orleans,
where the patient may have the benefit of
a very much more elaborate equipment,
greater laboratory facilities and highly
specialized staff which would be impossible
for reasons of cost to set up all over the
state.

Just a few high points have been touched
upon in this report of Senator Pepper.
There are many other features which can
and will be discussed more fully in the
future.

o

THE NEW ORLEANS GRADUATE

MEDICAL ASSEMBLY

There will be held, Office of Defense
Transportation willing, the ninth annual
meeting of the New Orleans Graduate Medi-
cal Assembly during the week of April
ninth. The meeting this year will be neces-
sarily curtailed to scientific presentations
alone. There will be no entertainments of
any kind and no commercial or scientific
exhibits. These restrictions are necessary
on account of war-time conditions. The 0.
D. T. has not granted permission to hold
this meeting but as it is purely scientific
and is of tremendous importance in the con-
tinuing education of many physicians, the
members of the Graduate Medical Assembly
feel that assent will be forthcoming from
the 0. D. T. '

That the Graduate Medical Assembly has,
in its nine years of activity, fulfilled a very

372

Editorials

definite need may be judged from the ever
increasing size of the meetings. From a
relatively small beginning the attendance
has increased by leaps and bounds. Not
only will there be at the coming meeting a
large group of civilian physicians but there
will be, as has been in the past three years
of war, a large group of medical officers
from the armed forces. This type of meet-
ing is particularly valuable for this group
because in the services the type of duty is
not always one which permits of the diag-
nosis and treatment of the sick man. That
the doctors of the armed forces must keep
up their knowledge of medicine is well ap-
preciated by the higher ranking medical
officers who have granted leaves for the
pupose of attendance at this meeting.

The program this year is fully up to the
splendid standards of the past. A group
of distinguished physicians will present
three or more subjects each in their special
fields. To mention a few of the partici-
pants in the program it might be said that
Dr. F. E. Weidman, Professor of Dermatol-
ogy, Graduate School of Medicine, Univer-
sity of Pennsylvania, is listed to speak on
three subjects, the most important of which
and most appropriate would seem to be a
presentation on post-war skin diseases. In
line with the war effort it might be also
noted that Captain Waltman Walters of the
Medical Corps, United States Naval Re-
serve and Professor of Surgery at the Uni-
versity of Minnesota Graduate School, will
discuss war injuries in naval and marine
personnel. Dr. S. A. Levine of Harvard
Medical School, whose book on clinical heart
disease is well known to all internists, has
four important talks listed which should
prove of interest to all physicians. Dr. A.
H. Aaron, president of the American Gas-
troenterological Association, will discourse
on pancreatic disease and diseases of the
biliary tract. Dr. G. C. Schauffler, of the
University of Oregon, has four interesting
titles on subjects having to do with gynecol-
ogy and obstetrics. Dr. R. L. Haden, chief
of the Medical Division of the Cleveland
Clinic Foundation will talk on his favorite
branch of medicine, the various aspects of

diseases of the blood. He will conduct a
clinico-pathologic conference in conjunction
with Dr. R. A. Moore, Professor of Path-
ology of Washington University School of
Medicine. Other distinguished physicians,
all of them parenthetically teachers, are
down on the program but space precludes
the possibility of enumerating the names of
these men or their subjects.

It is sincerely to be hoped that this meet-
ing will not be cancelled because very em-
phatically the officers and members of the
Graduate Medical Assembly realize that
such meetings are of distinct value to the
war effort.

o

BENZEDRINE IN OBESITY

Obesity is an interesting physiologic con-
dition which frequently becomes pathologic
and which under any circumstances is likely
to lead to pathologic complications. The
syndrome of hypertension, hyperglycemia
and obesity is beginning to receive general
recognition. If this syndrome persists for
a considerable period of time the hyperten-
sion may become irreversible and even
diabetes may develop. There are a host of
other complications but certainly that of the
concomitant hypertension is the one that is
most productive of associated vascular
changes which definitely shorten life to
such an extent that life insurance com-
panies are not likely to accept the individ-
ual because mortality tables show that
death occurs much earlier in life in the fat
person than in the average individual.

A few obese patients may suffer from
some type of endocrinopathy such as hypo-
function of the thyroid or of the gonads,
but these cases are rare. Stout people are
fat because they eat more than is needed
for their energy requirements. This is due
in great part to the fact that obese persons
apparently have a lower satiety value for
food than the normal person. Their ap-
petite is not satisfied when they have a
normal amount of food, so they eat more
than the ordinary person. These fat people
will disclaim ingesting more than the aver-
age amount of food but if they are asked to

Organization Section

373

keep a dietary diary it will be found that
the number of calories they take in is well
above their maintenance or energy needs.

In a recent paper Albrecht* points out
that it has been observed in the past that
benzedrine will cause a decrease in the ap-
petite, it delays the rate of evacuation of
the stomach, relaxes the organ and in-
creases pyloric tone.

Largely on the assumption that benze-
drine will reduce the appetite he adminis-
tered the drug to three hundred overweight
patients whose ages varied from 21 to 53
years. To these people were given from 10
to 30 milligrams of benzedrine daily in di-
vided doses, never ordering the drug to be
taken after four in the afternoon. There
were no dietary restrictions. When the op-
timal weight had been reached the patients
were then put on a low caloric diet. In 88
per cent of patients there occurred a loss
of appetite, in only 12 per cent was the
appetite increased. There were a few other

* Albrecht, F. K. : The use of benzedrine sulfate
in obesity, Ann. Int. Med., 21:983, 1944.

symptoms, including increased psychomotor
activity in 48 per cent of cases. Dryness
of the mouth was observed in some 56 per
cent of people. Strange to say insomnia
was noted in only 4 per cent.

The usual precautions were taken in pre-
scribing the drug. Individuals with well
marked hypertension, for example, did not
receive it. It is interesting that 26 per cent
of the people showed a gradual fall in the
blood pressure as their weight diminished,
40 per cent showed little or no change and
30 per cent had an increase of 8 mm. of
mercury systolic.

The author suggests that benzedrine sul-
fate may be a valuable adjunct in the man-
agement of patients who are overweight but
always under the supervision of a physi-
cian. After they have obtained normal
weight their caloric intake may be material-
ly reduced and they may go for long periods
of time without gaining weight as long as
they remain on the diet. Usually it is found
that they can adjust their abnormal appe-
tite at a new level and may not have to re-
sort to the drug, at least for many weeks.

ORGANIZATION SECTION

The Executive Committee dedicates this page to the members of the Louisiana
State Medical Society, feeling that a proper discussion of salient issues will contri-
bute to the understanding and fortification of our Society.

An informed profession should be a wise one.

THE PEPPER REPORT

The following are the eight recommen-
dations made by the Subcommittee on War-
time Health and Education, Senator Claude
Pepper of Florida as chairman, and re-
leased for publication on January 15 :

“1. Recommends that Federal grants-in-
aid to States be authorized now to assist
in post-war construction of hospitals, medi-
cal centers, and health centers, in accord-
ance with integrated State plans approved
by the United States Public Health Service.

“2. Recommends that Federal loans and
grants be made available to assist in post-
war provision of urban sewerage and water
facilities, rural sanitation and water facili-
ties, and milk pasteurization plants, in com-

munities or areas where such facilities are
lacking or inadequate.

“3. Urges State and local governments
to establish full-time local public health de-
partments in all communities as soon as
the needed personnel become available.
With this aim in view, consideration should
be given to rearrangement and consolida-
tion of local health jurisdictions and to
amalgamation of existing full- and part-
time local health departments with over-
lapping functions. The Federal Govern-
ment should increase the amount of its
grants to State health departments to the
end that complete geographic coverage by
full-time local health departments may be
achieved and that State and local public

374

Organization Section

health programs may be expanded in ac-
cordance with needs.

“4. Recommends that the Army consider
the feasibility and advisability of expand-
ing its program for induction and rehabili-
tation of men rejected because of physical
and mental defects.

“5. Recommends that the medical records
of the Selective Service System be pre-
served and that funds be appropriated for
further processing and study of these rec-
ords.

“6. Reports the acute shortage of per-
sonnel with training in psychology and
psychiatry and the need for immediate
steps to increase the output of such person-
nel with a view to providing child-guidance
and mental hygiene clinics on a far wider
scale.

“7. Recommends that Federal scholar-
ships or loans be made available to assist
qualified students desiring medical and
dental education ; urges that increased en-
rollment of women in medical and dental
schools, and premedical and predental
courses, be encouraged in every way pos-
sible.

“8. Recommends that Federal funds be
made available to States for medical care
of all recipients of public assistance and
that allotment formulas governing distribu-
tion of Federal funds to State public assist-
ance programs be made more flexible in
order to give more aid to States where
needs are greatest.”

We should look with seriousness upon
the last recommendation made by the Pep-
per Committee, as it provides for Federal
control over some forms of medical service.
(See editorial on page 370.)

o

COUNCIL ON MEDICAL SERVICE AND
PUBLIC RELATIONS

You should also be advised that recently
the Council on Medical Service and Public
Relations of the American Medical Associa-
tion at a meeting in Washington sent out
a statement for publicity prepared by Dr.
Louis H. Bauer, member of the Board of
Trustees and member of the Council on

Medical Service and Public Relations. Their
seven recommendations concerning the at-
titude of the medical profession toward pro-
viding adequate medical service are as
follows :

“1. Continued expansion of the practice
of medicine with full development of ap-
proved voluntary hospital, medical, indem-
nity, industrial and commercial insurance
against the costs of medical care.

“2. Development of public health facili-
ties for preventive medicine all over the
country.

“3. Development of adequate diagnostic
facilities everywhere.

“4. The use of the voluntary insurance
principle in caring for the indigent and
medically indigent.

“5. The development of hospital facilities
where present facilities are used to the ut-
most and are still inadequate.

“6. The use of Federal funds to aid com-
munities in public health measures, care of
the indigent and construction of necessary
hospitals, when local communities are un-
able to finance the projects, but with re-
tention of local administration.

”7. The creation of a unified Federal De-
partment of Health, as above outlined.”

It is interesting to note that the above
two sets of recommendations come from
entirely different sources, one from the
Congress of the United States and the other
representing a group working on similar
objectives. There is not a great variance
in some of their deductions and conclusions.
It does seem that it will be possible that
there could be developed adequate plans to
meet the requirements of all.

In addition to making these recommen-
dations, the Council also states that they
have authorized the appointment of a “Di-
rector of Insurance to correlate and coordi-
nate existing plans and assist in develop-
ing new ones so that the whole country may
be covered by available insurance plans.”
This innovation is something that has been
sorely needed by the various states in cor-
relating the various medical insurance
plans to fit the exact needs of their respec-
tive states. We will thus have the oppor-

Orleans Parish Medical Society

375

tunity of having presented to us in a con-
cise form some valuable help in reaching
our conclusions concerning these important
features of medical service.

In keeping with the above you should
know that we have in this state a very
active and energetic committee giving se-
rious consideration to bringing in some rec-
ommendation to our House of Delegates
concerning voluntary prepayment medical
insurance. Also there is a committee in
the state working on some plans for a solu-
tion of improving the physical fitness of
the youths of our state.

It is rather interesting to observe why so
much emphasis is placed on inadequate
medical service being the cause of all of
our physical and mental defects, when the
basic factors which regulate and provide
good healthy bodies have been denied the
people. Medical service is only one of the
many links in the chain for the strength
and health of our people. Therefore, the
ideal results can only be accomplished when
all’ of the factors are properly coordinated
and each given a positive phase. Our
health can only be as strong as the weak-
est link. True, it is the old saying that
disease and poverty go hand in hand, but
why try to remedy only the disease when we
permit the continuance of poverty and basic
factors for bad health. We must, there-
fore, not be deluded into a sense of secur-
ity. The 78th Congress completed their ses-
sions without ever having brought the fa-
mous Wagner-Murray-Dingell bill, Senate
No. 1161 for hearing even before a com-
mittee. It was evidently realized that such
a drastic change in the distribution of
medicine and benefits under this amend-
ment could not be passed. In the December
23 issue of the American Medical Associa-
tion Journal attention is drawn to the fact
that Representative John D. Dingell, Dem-

ocrat, of Michigan, co-author of this amend-
ment in the House, had given out a state-
ment that he proposes “to salvage portions
of the project he proposes that the big bill
be split into several sections to be submit-
ted to the new Congress opening in Jan-
uary.” He furthermore states that he con-
siders some form of public health and hos-
pitalization insurance with wage earners
helping to pay for it should be made a law,
but he is against socialization of medicine.
In keeping with this it is very interesting
to note that just last week a bill was intro-
duced by Representative Dingell, H. R. Bill
395, which “proposes to create a Unified
National Social Insurance System to pro-
vide, among other things, temporary and
permanent disability benefits and medical
and hospitalization insurance benefits. The
medical provisions of this bill are identical
with those contained in the Wagner-Mur-
ray-Dingell bill introduced in the 78th
Congress.”

So again the medical profession is called
upon to be ever diligent, for it does seem
that it is the intention of some of these so-
called social minded people to set upon the
shoulders of the American public, contrary
to their wishes, this nefarious project.
o

ANNUAL STATE MEETING

Owing to the recent ruling of the Office
of Defense Transportation, it was neces-
sary for our organization to make applica-
tion to them for the privilege of holding
our annual meeting on April 13. We have
reason to believe that this application will
be favored. However, it may be that the
Office of Defense Transportation might
order us to call off the meeting entirely.
Just as soon as we get some positive infor-
mation you will be informed through the
pages of the Journal.

_ — — o —

TRANSACTIONS OF ORLEANS PARISH MEDICAL SOCIETY

February 1. Clinico-pathologic conference, Tou- February 5. Board of Directors, Orleans Parish
ro Infirmary, 12:00 noon. Medical Society, 8 p. m.

Executive Committee, Baptist Hos- February 6. Eye, Ear, Nose and Throat Staff,
pital, 8 p.m. 8 p. m.

376

Louisiana State Medical Society News

February

t .

February

12.

February

14.

February

15.

February

16.

February

19.

February

20.

February

21.

February

22.

February

23.

February

27.

Februarv

28.

Mercy Hospital Staff, 8 p. m.

Scientific Meeting, Orleans Parish
Medical Society, 8 p. m.

Woman’s Auxiliary, Orleans Par-
ish Medical Society, Orleans
Club, 3 p. m.

Clinico-pathologic conference, Ma-
rine Hospital, 7 :30 p. m.

Touro Infirmary Staff, 8 p. m.

Clinico-pathologic conference, Tou-
ro Infirmary, 12:00 noon.

I. C. R. R. Hospital Staff, 12:30
p. m.

Hotel Dieu Staff, 8 p. m.

Charity Hospital Medical Staff, 8
p. m.

Charity Hospital Surgical Staff, 8
p. m.

DePaul Sanitarium Staff, 8 p. m.

New Orleans Hospital Dispensary
for Women and Children Staff,
8 p. m.

Baptist Hospital Staff, 8 p. m.

French Hospital Staff, 8 p. m.

Clinico-pathologic conference, Ma-
rine Hospital, 7 :30 p. m.

o

NEWS ITEMS

The Southwest Allergy Forum will hold its an-
nual meeting at the Jung Hotel on April 9-10.

Dr. Robert F. Sharp and Dr. William B. Clark
appeared on the program of the South Mississippi
Medical Society at a meeting in Hattiesburg, De-

cember 14. Dr. Sharp spoke on “Significant Uro-
logical Symptoms in Pediatrics,” and Dr. Clark
on “The Management of Some Common Eye Prob-
lems.”

Major George M. Haik has recently been elected
to fellowship in the American College of Surgeons.
He writes that the 64th General Hospital, to which
he is attached, is now the ophthalmic center for
Northern Italy.

Dr. Samuel B. Nadler has been elected to mem-
bership in the American College of Physicians.

Major John Herring is serving as a flight sur-
geon in the China-India-Burma Theater.

Dr. Gretchen M. V. Squires has been certified
by the American Board of Pathology.

Dr. John M. Whitney spoke at the Mid-City
Kiwanis Club on Public Health Service in New
Orleans.

At a recent meeting of the Southern Medical
Association in St. Louis Dr. Grace Goldsmith was
elected chairman of the Section on Medicine.

At a meeting of the War-Time Graduate Medi-
cal Education held at the Camp Plauche Hospital
December 27, Drs. Donovan Browne and Urban
Maes spoke on bleeding peptic ulcer, and Dr. Fred-
erick F. Boyce spoke on diseases of the liver and
the role of the liver in surgery. The committee
for the meetings consists of Dr. Howard Mahor-
ner, chairman, and Drs. Urban Maes and Edgar
Hull.

LOUISIANA STATE MEDICAL SOCIETY NEWS

CALENDAR

PARISH AND DISTRICT MEDICAL SOCIETY

Date

Rouge Second Wednesday of every month

Second Tuesday of every month

Second Monday of every month
First Thursday of every month
First Monday of every month
First Wednesday of every month
Third Thursday of every month
First Tuesday of every month
First Thursday of every month

MEETINGS

Place

Baton Rouge
Bastrop

New Orleans

Monroe

Alexandria

Shreveport

Society
East Baton
Morehouse

Orleans
Ouachita
Rapides
Sabine

Second District
Shreveport
Vernon

EAST BATON ROUGE MEDICAL SOCIETY

At a recent meeting of the East Baton Rouge
Parish Medical Society the following officers were
elected for the year 1945: President, Dr. Felix
Boizelle; Vice-President, Dr. W. R. Eidson; Sec-
retary-Treasurer, Dr. C. H. Voss; Delegates, Drs.
T. J. McHugh, H. Guy Riche, A. D. Long, U. S.
Hargrove, and H. C. Hatcher; Alternates, Drs.

J. A. Durand, J. D. Martin, J. E. Toups, J. O.
Hoth, and E. G. Cailleteau; all of Baton Rouge.

o

VERNON PARISH MEDICAL SOCIETY

At a recent meeting of the Vernon Parish Med-
ical Society the following officers were elected
for the year 1945:

Louisiana State Medical Society News

377

President. Dr. John B. Younger, Kurthwood;
Vice-President, Dr. T. A. Hendrick, Leesville; Sec-
retary-Treasurer, Dr. Wm, M. Johnson, Leesville;
Delegate, Dr. M. W. Talbot, Leesville.

o

TERREBONNE PARISH MEDICAL SOCIETY

The following officers will serve for the year
1945 for the Terrebonne Parish Medical Society:
President, Dr. W. A. Ellender; Vice-President, Dr.
T. I. St. Martin; Secretary-Treasurer, Dr. S. C.
Collins.

o

FIFTH DISTRICT MEDICAL SOCIETY

The meeting of the Fifth District Medical So-
ciety was held in the middle of the month of Jan-
uary at Monroe at the Francis Hotel. Dr. W. A.
Rodgers of Bastrop was elected president to
succeed Dr. D. T. Milam of Monroe. Dr. J. E.
McConnell of Monroe was re-elected as secretary-
treasurer, and Dr. W. L. Bendel was elected as
alternate delegate.

The scientific meeting following the dinner was
participated in by Dr. E. E. Barlow of Wilmot,
Arkansas, Dr. E. L. King of New Orleans who
spoke on the “Toxemias of Pregnancy,” and Dr.
J. H. Musser of New Orleans who spoke on “Viral
Pneumonia.”

o

REGIONAL MEETING OF THE AMERICAN
COLLEGE OF PHYSICIANS

There was held at the Hotel Peabody, Memphis,
January 25-26, a regional meeting of the Ameri-
can College of Physicians in which the membership
of the states of Louisiana, Mississippi, Tennessee,
Arkansas and eastern Texas took part. Dr. Edgar
Hull, the College Governor for Louisiana, pre-
sided at one of the sessions and also presented a
paper on bacterial endocarditis.

| o

SOUTHERN BAPTIST HOSPITAL

The regular clinical staff meeting of the South-
ern Baptist Hospital was held on December 16 at
8 p. m. After a short discussion by Dr. W. H.
Gillentine of the deaths that occurred in the in-
stitution, refreshments were served.

o

CHARITY HOSPITAL

A meeting of the Medical Division of the Char-
ity Hospital Visiting Staff was held on Tuesday,
January 16 at 8 p. m. in the auditorium of the
hospital. The following program was presented:
Periarteritis Nodosa by Drs. J. S. LaDue and E.
Mendal; Early Immunization Against Pertussis by
Dr. W. Sako. A case of alcoholism, with peripheral
neuritis and other evidences of vitamin deficiency,
syphilis and a gastric ulcer which has been under
observation by Drs. Goldsmith and Musser for
some years, was presented by Dr. S. W. Westfall.

SOCIETY FOR EXPERIMENTAL BIOLOGY
AND MEDICINE

The Southern section met on January 12, 1945,
at 8:00 p. m. in the Richardson Memorial Build-
ing, on the Tulane campus. The following pro-
gram was presented :

1. A Comparison of Simultaneous Records of
Changes in Serum Glucose, Serum Potassium and
Blood Pressure after Epinephrine. Foster N.
Martin, Jr. (Introduced by Dr. Ralph S. Smith),
Department of Pharmacology, Tulane Medical
School.

2. The Effect of 2-Methyl-Amino-Heptone on
Dogs under Cyclopropane Anesthesia. John Adri-
ani and E. C. Heringman (by invitation), Depart-
ment of Surgery, L. S. U. School of Medicine.

3. On the Chemotherapy of Tuberculous Infec-
tions. Clyde Brooks, Department of Pharmacol-
ogy and Experimental Therapeutics, L. S. U.
School of Medicine.

4. The Effect of Heart Cycle Length on the T
Wave of the Electrocardiogram. Richard Ashman,
Frederick P. Ferguson (by invitation), Alice In-
graham Gremillion (by invitation), and Edwin
Byer (by invitation), Department of Physiology,
L. S. U. School of Medicine.

5. Rheumatic Carditis in Association with the
Wolff-Parkinson-White Syndrome. Richard Ash-
man, J. P. Melvin (by invitation) and Ross C.
Tilbury (by invitation), Departments of Physiol-
ogy and Pediatrics, L. S. U. School of Medicine
and The Charity Hospital of Louisiana at New
Orleans.

6. Diffusion of Water through Dead Plantar,
Palmar and Torsal Skin and through Toe Nails of
Man. Geox'ge E. Burch and Travis Winsor (by in-
vitation), Department of Medicine, Tulane Medi-
cal School.

7. Use of the Phlebomanometer, Establishment
of Normal Values, and a Study of Certain Clinical
Aspects of Venous Hypertension in Man. Travis
Winsor (by invitation) and George E. Burch, De-
partment of Medicine, Tulane Medical School.

o

TOURO INFIRMARY

The annual meeting of the Medical Staff was
held on Wednesday, January 10 at 8 p. m. The
scientific program consisted of a clinico-pathologic
conference, a clinical discussion of which was led
by Dr. Sydney Jacobs. Following this Dr. D. N.
Silverman presented a paper on peptic ulcer com-
plicating dysentery. Following the scientific ses-
sion the annual election to the Executive Commit-
tee of two representatives from the staff at large
was conducted. Dr. B. B. Weinstein and Dr. J. D.
Russ were the selections of the staff.

— o

CONGRESS ON INDUSTRIAL HEALTH

The Council on Industrial Health of the Ameri-
can Medical Association regrets to announce that
the Seventh Annual Congress on Industrial Health,

378

Louisiana State Medical Society Neivs

scheduled to convene February 13-15, will not be
held.

This action is taken in compliance with a re-
quest received from the Office of Defense Trans-
portation.

The Annual Congress on Medical Education and
Licensure has been called off on account of dif-
ficulties in transportation. This meeting was
scheduled to be held in Chicago at the Palmer
House on February 12 and 13.

o

SPRING REFRESHER COURSE IN
OTOLARYNGOLOGY

The fifth semi-annual refresher course in laryn-
gology, rhinology and otology will be conducted by
the University of Illinois, College of Medicine at
the College in Chicago, March 26 to 31 inclusive,
1945. While the course will be largely didactic,
some clinical instruction will be included. This
course is intended primarily for ear, nose and
throat specialists. As the registration is limited
to thirty, applications will be considered in the
order in which they are received. The fee is $50.
When writing for application please give details
concerning school and year of graduation, and
past training and experience. Address — Dr. A. R.
Hollender, Chairman, Refresher Course Commit-
tee, Department of Otolaryngology, University of
Illinois, College of Medicine, 1853 West Polk St.,
Chicago 12, Illinois.

o

DOCTORS FOR THE NAVY

The serious need for physicians in the U. S.
Naval Reserve is emphasized in recent communica-
tions from the Bureau of Naval Personnel of the
Navy Department. Since the Army discontinued
the commissioning of physicians, it was anticipated
that the procurement of physicians by the Navy
would be increased. Actually the number of phy-
sicians commissioned in the U. S. Naval Reserve
has been decreasing. Three thousand physicians
are needed as soon as possible to ease the emer-
gency which now exists. Even this number will
not actually satisfy the demand.

Louisiana has already contributed more than
its share of physicians to the various services, but
it is necessary to secure every physician who is
not absolutely essential to the health and welfare
of your state.

Many physical defects may be waived for com-
mission in the'U. S. Navy Medical Corps Reserve.
This is being done in order to help fill the urgent
need of medical officers. The age limit is now
55. Doctors up to the age of 60 may apply for
commission and be assigned to the U. S. Veterans
Administration. Rank is based on both age and
experience.

Any applicant should consult the State Chair-
man of Procurement and Assignment Service for
Fhysicians regarding his possible release and then

contact the Director of Naval Officer Procure-
ment, 611 Gravier St., New Orleans, La.

o

THE CRITICAL NURSE SHORTAGE

“Our battle casualties are mounting daily,” Ma-
jor General Norman T. Kirk, The Surgeon Gen-
eral, stated at Mayor La Guardia’s Nurse Recruit-
ing Meeting in New York City, on January 4.
“Not only has this increased the nursing problem
overseas,” he continued, “but it increases the
problem of taking care of those casualties who are
being returned from overseas.

“Last month over thirty thousand wounded and
sick were returned to the United States by air-
plane and hospital ship. We expect that this
number will be even greater this month. These
men all need nursing care. We had foreseen this
emergency. Since last October the Army Medical
Department has been stressing the need for 10,000
additional nurses. We sent a personal appeal to
each one of the 27,000 nurses that the War Man-
power Commission told us were available for
duty. Our returns from that appeal were pitiful.
We received 760 answers and signed up 227 nurses
from that group.

“This same shortage of nurses is evident in the
Zone of the Interior. On January 2 Percy Jones
General Hospital had 3699 hospital and convales-
cent patients. There were 85 army nurses there
to take care of them. That is a ratio of 1 nurse to
43 patients. In addition to the army nurses there
were 33 civilian nurses, 23 nurse’s aids and 36
WAC technicians.. Including the civilian nurses,
and nurse’s aides, the ratio is still 1 to 26.

“The situation has grown so critical that sug-
gestions have been made that the Army draft
nurses through Congressional action. It looks as
if this will be necessary to meet the immediate de-
mand for nurses.”

Forty-eight hours later, in his message to Con-
giess, President Roosevelt said, “Since volunteer-
ing has not produced the number of nurses re-
quired, I urge that the Selective Service Act be
amended to provide for the induction of nurses
into the armed forces. The need is too pressing to
await the outcome of further efforts at recruit-
ing.”

o

INFECTIOUS DISEASES IN LOUISIANA

The morbidity report of the Louisiana State De-
partment of Health showed that for the week end-
ing December 8 there were reported the following
diseases in numbers greater than 10, — 29 in-
stances each of unclassified pneumonia and of
malaria, 21 of pulmonary tuberculosis, 15 of diph-
theria, and 14 of scarlet fever. The diphtheria
cases occurred throughout the state, no one par-
ish reporting more than two cases except Orleans
with three. The malaria patients were discovered

Louisiana i State Medical Society News

379

in Grant and Jefferson Parishes largely. One
case of smallpox was reported from Claiborne
Parish. In the following- week which ended De-
cember 16 there were 36 cases of malaria re-
ported, 29 of unclassified pneumonia, 21 of pul-
monary tuberculosis, 20 of scarlet fever, and 10
of diphtheria. Calcasieu Parish reported six of
the cases of diphtheria. Grant and Jefferson
Parishes reported most of the cases of malaria.
The following week which closed December 23
malaria led the reportable diseases with 35 cases,
followed in order of frequency with 18 of unclass-
ified pneumonia, 17 of pulmonary tuberculosis,
14 each of diphtheria and of mumps, 11 of influ-
enza, and 10 of scarlet fever. This week the
diphtheria cases were scattered over the state.
Twenty of the malaria patients were reported from
Jefferson Parish. The week ending December
30, in which week the total four weeks’ report of
venereal diseases is given, showed that of these
diseases there were in the month 1,014 cases of
gonorrhea reported, 844 of syphilis, 27 of chan-
croid, and 10 of lymphopathia venereum. Of the
other diseases non-venereal in nature, pulmonary
tuberculosis was next to the fore with 79 cases
reported, followed by 27 of malaria, 19 of un-
classified pneumonia, 17 of scarlet fever, and 12
of mumps. The malaria cases again came largely
from Grant and Jefferson Parishes. The total
number of pulmonary tuberculosis cases was rather
surprising, as in the previous four weeks exactly
the same numbers were reported as were reported
for this last week in the year.

o

HEALTH OF NEW ORLEANS

There was really a very extraordinary drop in
the number of deaths in the first week of the year,
there being only 115 citizens of New Orleans dying-
in this particular week. Seventy-nine of the
deaths were in white people and 36 in the colored,
and 9 of the deaths were in small children.

MONTHLY STATISTICAL REPORT
DECEMBER, 1944

FROM THE NEW ORLEANS DEPARTMENT
OF HEALTH

Estimated Population as of July 1, 1944

WHITE 391,000

COLORED 169,000

TOTAL 560,000

Total Deaths, All Causes 729

WHITE 481

COLORED 248

Resident Deaths, All Causes 597

WHITE 400

COLORED 197

DEATH RATES

(Per 1000 per annum for the month)

All Non-residents

Deaths excluded

WHITE 15.8 12.3

COLORED 17.6 13.9

TOTAL 15.6 12.8

Total Births Recorded 1223

WHITE 784

COLORED 439

The Bureau of the Census, Department of Com-
merce reported that for the week ending- Decem-
ber 16 there were exactly as many deaths in the
city as in the previous week. These deaths were
divided 110 white, 55 colored, and seven of these
were in children under one year of age. The fol-
lowing week the changes were inconsequential.
There were three more deaths in the city than in
the previous week, these being divided 120 white,
48 colored, with 15 deaths in small children. The
figures for the deaths of the city remained re-
markably consistent for the last week in the year.
There were 161 total deaths, 109 white, 52 col-
ored, and of these total deaths eight were in in-
fants. For the previous year there had been 181
deaths in that particular week. It is interesting
to note that in 1943 there were a total of 7,706
deaths. This was a remarkably healthy year, but
the year of 1944 there were only 7,493 deaths.
This was really a most unusual record as un-
doubtedly the city for the last year has increased
its population. The diminished number of deaths
fell about equally between the two races. There
were, however, 390 deaths in infants as contrasted
with 362 in the year 1943.

Resident Births 953

WHITE 603

COLORED 350

(Per 1000

BIRTH RATES
per annum for the

month)

All

Non-residents

Deaths

excluded

WHITE

24.1

18.5

COLORED

31.1

24.8

TOTAL

26.2

20.4

DR. GEORGE F. ROELING
(1886-1945)

The many friends of the genial and popular ex-
coroner, Dr. George F. Roeling, were dismayed to
hear of his sudden death while en route to his of-
fice in his automobile on January 12, 1945. Dr.
Roeling at the time of his death was city alienist
and superintendent of the City Hospital for Mental
Diseases. He was active in the Charity Hospital
where he was on the visiting staff serving in his
specialty of neuropsychiatry.

380

Book Reviews

DR. ROBERT B. STILLE
(1905-1945)

Dr. Robert B. Stille died suddenly of a heart
attack in Many, La., on December 26, 1944. Dr.
Stille was a graduate of the Tulane School of
Medicine, class of 1930. He was a member of the
honorary medical fraternity, Alpha Omega Alpha
— having been elected to membership in 1929.
After graduating from Medical School, Dr. Stille
interned at the Charity Hospital in New Orleans
from 1930 to 1932 (for two years). In the sum-
mer of 1932 Dr. Stille began the practice of his
profession in his home town of Many, Louisiana
where he was located until his death on December
26, 1944.

In addition to his practice Dr. Stille was a Di-
rector of the Sabine State Bank and Trust Com-
pany from 1930 until his resignation in April 1944.
Dr. Stille was a member of the Sabine Parish
Medical Society, of the Louisiana State Medical
Society, and of the American Medical Association.
He was an active member of the First Baptist
Church of Many, Louisiana and took a very active
part in all community affairs.

WOMEN’S AUXILIARY TO THE
LOUISIANA STATE MEDICAL SOCIETY

December News Report

Parish auxiliaries, reconvening during the fall,
have directed their activities along various chan-
nels. Meeting with groups at their regular
monthly meetings, the State Auxiliary president,
Mrs. Rhodes Spedale, reports the sponsoring of
many noteworthy projects in addition to routine
carrying out of the state program.

The Shreveport Blood Bank, to be created and
maintained by the Medical Auxiliary in that city,
offers a highlight of interest. Acting under the
inspiration and direction of the Parish Medical
Society, the doctors’ wives will have entire charge
of the project.

The problems of post-war medicine are being
delved into by the far-seeing women of the
Ouachita group, who have inaugurated a program
which they will be glad to discuss and augment
with interested auxiliaries. In addition to the war
time phases entered into by busy dostors’ wives,
the ladies of the Rapides Auxiliary have unobtru-
sively added a piece of work with a definite post-
war future. They have established a circulating
library for bedridden patients in one of the hos-
pitals, and collect and distribute the books twice
weekly.

Both Mrs. Spedale and the chairman of publicity
would welcome the opportunity to publish material
of interest to the members at large concerning the
activity of each of the eighteen active units. Re-
ports may be addressed either directly to Mrs.
Spedale or to 720 Broadway, New Orleans 18, La.

The importance of each Auxiliary partaking ac-
tively in the program to impress the public with
the menace of the W’agner-Murray-Dingell Bill
cannot be too gieatly emphasized. All parish
auxiliaries are directed that one meeting be de-
voted to having a doctor, or a member versed on
the subject, discuss the injustice this bill would
inflict upon the public. Guests should be invited
for this meeting in order to reap as much benefit
as possible from the effort and time devoted to the
topic. Publicity chairmen of the individual groups
are urged to secure as much local attention as their
ingenuity may devise and to report in full all ma-
terial to the medical groups with which they are
associated.

The selection of our Mrs. A. A. Herold as Con-
stitutional Secretary of the Auxiliary to the Amer-
ican Medical Association seems very natural to
those who know her capabilities so well, but is
nevertheless an outstanding tribute to the indi-
vidual and to the organization she has so ably
represented. Another transaction of the National
Convention which will be of interest to all con-
cerns the amendment of the entire constitution
and by-laws of the national group. The revised
copy will appear elsewhere in the current issue of
the Journal. The discussion concerning the revi-
sion was- ardent and impetuous, and it behooves
each member to study the new document of the
parent organization very carefully. Participating
in the National Convention were the Louisiana
State Auxiliary president, Mrs. Rhodes Spedale,
Mrs. A. A. Herold of Shreveport, Mrs. Donovan
Browne, Mrs. Roy B. Harrison, and Mrs. Cassius
Peacock, all of New Orleans.

In her capacity as Constitutional Secretary for
the Women’s Auxiliary to the American Medical
Association, Mrs. Herold, accompanied by Mrs.
Spedale, attended the Conference in Chicago on
November 16 and 17. The interesting and en-
lightening reports from the presidents attending
the meeting will be incorporated in messages
these ladies will transmit later to various groups.

Mrs. John S. Dunn, 8410 Pontchartrain Boule-
vard, New Orleans, La., as State Historian asks
that the responsible member in each of the parish
auxiliaries transmit to the historian material ap-
propriate for the State history book. Mrs. Melton,
of Plaquemine, Corresponding Secretary, is
anxious to complete her list of officers of the va-
rious parish units.

The re-organization of the Second District under
the councilorship of Mrs. Roy B. Harrison is noted
with enthusiasm and appreciation. The date of
the annual session of the society, Friday, April 13,
must be given special consideration. According to
Dr. Talbot, Secretary-Treasurer of the Louisiana
State Medical Society, the executive committee has
decided to have only a one day meeting in 1945
instead of the usual four day annual session. The

Book Reviews

381

decision was found necessary owing to war con-
ditions; affecting hotel reservations, accommoda-
tions for exhibits, meeting halls and transporta-
tion, all of which if arranged for would be sub-
jected to change upon short notice by military
necessity.

The president’s greeting of “A Victory in the
New Year” is a fitting note upon which to close
this report.

Respectfully submitted,

(Mrs. Edwin R.) Mazie Adkins Guidry,

Chairman of Press and Publicity.

o

BOOK REVIEWS

1. Anti-malarial Drugs : By Owsei Temkin, M. D.
and Elizabeth M. Ramsey, M. D. 2. The Blood
Plasma, Program : By James A. Phalen, M. D.,
Colonel, U. S. Army. 3. Spontaneous Pneumo-
thorax: By James J. Waring, M. D. 4. Keys to
the Mosquitoes of the Australasian Region: By
Kenneth L. Knight, Lieutenant, H-V (S), US NR,
Richard M. Bohart, Lieutenant (jg), H-V (S),
USNR, and George E. Bohart, Lieutenant, H-V
(S), USNR. Washington, D. C., National Re-
search Council, 1944.

These are a group of four reports issued by the
Office of Medical Information which contain the
latest material which has to do with their subject
matter. As with any paper issued by the National
Research Council, their content may be relied upon
as being complete, full, and authoritative.

J. H. Musser, M. D.

Surgical Errors and Safeguards: By Max Thorek,
M. D., D. C. M., F. I. C. S. 4th ed. Philadelphia,
J. B. Lippincott Co., 1943. Pp. 1085 illus. Price
$15.00.

This work of Thorek has filled a need in sur-
gical literature as is attested by the fact that this
new edition (4th) has been called for. There is
little to criticize. The illustrations are excellent.
The new chapter on the medical-legal aspects of
surgical practice by H. W. Smith is a valuable ad-
dition to this revised edition. One might suggest
that in future editions of this book more considera-
tion be given to the errors and safeguards con-
cerned w'ith the diagnosis and treatment of injuries
of the abdomen and thorax. The book can be highly
recommended to younger surgeons.

H. A. Davis, M. D.

Textbook of Pathology: By E. T. Bell, M. D. 5th
ed. enl. and rev. Philadelphia, Lea & Febiger,
1944. Pp. 862, pi. illus. Price $9.50.

The fourth edition of Dr. E. T. Bell’s Textbook
of Pathology embodies the same lucidity so charac-
teristic of the earlier editions. The illustrations
have been increased from 431 to 448, and two new
color plates have been added. The new edition has
some 130 less pages than the previous one.

On reading Dr. Bell’s Textbook, one is instantly
aware of the close and thorough study of the lar-
gesse of material available to the author. In so far
as 25 per cent of all persons dying in Minneapolis
over one year of age come to autopsy, one can

readily see the tremendous influence played by the
author in making the department a pathological
mecca. Fact and fancy are well separated, and
conclusions are painstaking and conservative. Be-
cause of the enormous accumulated material
studied year after year, very little need be “bor-
rowed”. One is often pleasantly surprised after
spending considerable time in perusing the litera-
ture on a certain problem, to go back to this book
and find the essentials completely and neatly dealt
with in a few concise sentences. It is this attribute
of the author to express things simply, lucidly,
concisely and authoritatively that makes this text-
book outstanding for the student of medicine,
whether he be an undergraduate or a graduate.

This brevity may have a few drawbacks especial-
ly the newer material in which the reader may wish
some added information. The separation of vita-
min deficiencies in Chapter 5 in the fourth edition
is a distinct advantage to its scattered mention
in the previous editions. However, not all of the
substances comprising the vitamin B complex are
mentioned. It seems since biotin is discussed such
substances as pantothenic acid, para-aminobenzoic
acid, inositol and folic acid should also be con-
sidered. Possibly the coenzymatic function should
have been further developed in consideration of
thiamine. Choline is discussed as a lipotrophic
factor in another chapter.

Retrogressive changes are admirably dealt with.
The Virchowian elements so frequently present in
many texts are swept aside, as for example the
concept of albuminous granules in cloudy swelling.
The chapter on inflammation is excellent and em-
bodies the newer concepts of the subject. Under
congenital syphilis the author mentions the intra-
lobular cirrhosis present, but the frequency of this
in our material emanating from Charity Hospital
has not been too impressive. Under leprosy there
does not seem to be too clear a distinction between
the histological forms. An excellent discussion of
Boeck’s sarcoid and its relation to Heerford’s syn-
drome is present although no mention of tuberculin
anergy is encountered. The section on virus and
richettsial diseases is well written.

It would be exceedingly worthwhile for anyone
dealing with malignant disease to study this sec-
tion carefully. There are so many excellent things
presented that the reviewer is tempted to comment
on all. A few of these will be considered. They

382

Book Reviews

have the ring of aphorisms true and tested. Such
statements as “A tumor is as malignant as its most
malignant part” is a magnificent fundamental
statement, and bears out in clinical practice. To
the reviewer, attempting to categorize empiricism
and translate this to the patient in forms of dis-
tinct grading has been overdone, and in some in-
stances is certainly of doubtful value, and is in
conformity with the views of the author. As a
corollary postulate to this comes the statement,
“making a prognosis or recommending treatment
in the clinical and biological characters are often
more important than its histologic structure”. It
would be well for oncologists to hearken to this
aphorism.

In the never never land between the normal and
malignant the pathologist is tempted to place on it
Grade I. The author admonishes where this un-
certainty exists grading should not be used. The
author stresses one important fact, in which the
reviewer is in complete accord, that it is important
to recognize Grade I fibrosarcoma. The applica-
tion of “sarcoma” to the uninitiated surgeon and
pathologist usually results in radical procedures.
Less radical! procedures can be considered here and
that has been the reviewer’s experience.

In the fundamental concept of neoplasia the
newer important work is clearly brought forth. The
objections to Cohnheim’s hypothesis is timely. The
role of chronic inflammation is modified to meet
modern conceptions. Under osteogenic sarcoma,
he states that a classification based on histological
structure is unsatisfactory since several types of
tissue are present, and further if the pathologist
assumes the responsibility for diagnosis, he should
examine the patient, study the roentgen-ray plate
and be present at the operation. This is excel-
lent counsel an dshould be taken to heart by path-
ologists.

The reviewer is in full accord with his comment
on the narrowing field of endothelioma and shed-
ding proper light on the nature of Ewing’s tumor.
The author follows Bailey and Cushing’s classifi-
cation of the gliomata. The illustrations are ex-
cellent and clear, especially the astrocytomas, which
show the gemistic as well as the stellate variety.
Ependymomas might be extended to include the
variations. In accord with the author it has been
also our experience that the histologic grading of
carcinoma of the cervix has little practical value.
Late recurrences as long as 10 years following
mastectomy have been brought out, which is very
valuable information.

The section on diseases of the blood is introduced
by a description and colored plates of the cells.
Erythroblastosis fetalis and the Rh factor is dis-
cussed well. In polycythemia the significance of
the Giesbock’s syndrome is brought out. Primary
splenic neutropenia is discussed. The difficulty in
distinguishing aleukemic reticuloendotheliosis from
secondary hyperplasia of the reticulum is rightly
alluded to.

The section on the liver is well written and ema-
nates from the experience of a large volume of
material. Many of the confusing ideas prevalent
are “straightened out”. The section on the cardio-
vascular system is well illustrated and written.
Recurrent rheumatic endocarditis is emphasized.
Acute and chronic cor pulmonale which is not
myocarditis is discussed.

Under the chapter of the kidney there is very
little one can say that has not been said by many
already. It represents a unique and distinct mile-
stone in the understanding of renal disease and
should constitute a part of the armamentarium of
clinicians and pathologists. Additional descriptions
of the kidney in disseminated lupus erythematosis
is discussed.

The diseases of the glands of internal secretion
are well handled. The author rightly points out
that the term Cushing’s syndrome is more appro-
priate than pituitary basophilism and stresses the
recent work of Crooke. Under neuropathology the
various types of encephalitis are well handled. The
chapter on bone has excellent photographs and good
discussion. Very little space is given, however, to
joints.

Having read the book, one is impressed with the
vastness of material presented in a small space. It
is a book which is a valuable asset to the clinician
as well as the student. It can be recommended
very highly.

Bjarne Pearson, M. D.

PUBLICATIONS RECEIVED

W. B. Saunders Company, Philadelphia and
London: Manual of Clinical Mycology, Prepared

Under the Auspices of the Division of Medical
Sciences of the National Research Council. Clin-
ical Heart Disease, by Samuel A. Levine, M. D.,
F. A. C. P.

J. B. Lippincott Company, Philadelphia: Medical
Uses of Soap, Edited by Morris Fishbein, M. D.

The Williams & Wilkins Company, Baltimore:
The Etiology, Diagnosis, and Treatment of Ame-
biasis, by Charles Franklin Craig, M. D., M. A.
(Hon.), F. A. C. S., F. A. C. P., Colonel, U. S.
Army, Retired, D. S. M. The Avitaminoses, by
Walter H. Eddy, Ph. D. and Gilbert Dalldorf,
M. D.

Harvard University Press, Cambridge, Mass.:
F amilial Susceptibility to Tuberculosis, Its Import-
ance as a Public Health Program, by Ruth Rice
Puffer, Dr. P. H.

Lea and Febiger, Philadelphia: The Pathology

of Internal Diseases, by William Boyd, D. D.,
LL.D., M. R. C. P., Ed., F. R. C. P., Lond., Dipl.
Psych., F. R. C. S.

Grune and Stratton, Inc., New York: Personal
Mental Hygiene, by Dom Thomas V. Moore.

John Wiley and Sons, Inc., New York: Intro-

duction to Parasitology, by Asa C. Chandler, M. S.,
Ph. D.

New Orleans Medical

and

Surgical Journal

Vol. 97 MARCH, 1945 No. 9

RUPTURED INTESTINES

THE RESULT OF NON-PENETRATING
TRAUMA

A CASE REPORT

•JACOB M. BODENHEIMER, M.D.

Shreveport, La.

Severe and very often fatal injury to one
or more of the abdominal viscera may re-
sult from direct blows or indirectly from ex-
plosions in the air or water. A sudden
blow on the abdomen from a fist, a block of
wood, or abdominal trauma from automo-
bile accidents have resulted in serious and
often fatal internal injuries. The numer-
ous reports of people taken out of the
wrecks of buildings during the London
blitz, in apparently good condition, only to
die within a very short time, the fatal re-
sults observed in many who received the
concussions from depth bombs in the water,
have but recently drawn our attention to
this form of accident.

As revealed by operations or postmor-
tems, the character and extent of these in-
juries have been amazing. Livers and
spleens have been torn to shreds, the kid-
neys have been injured beyond repair, the
bladder has been ruptured, intestines have
been completely severed, the omentum has
been torn asunder and blood vessels of va-
ious sizes severed. These, of course, rep-
resent the extremes of the injuries which
are well nigh always fatal. There are other
less severe injuries which after careful and
painstaking examination backed by expe-
rience and good sound judgment, may be
relieved by operation. Hemorrhage must
be differentiated irom shock, pain must be
properly evaluated, and once the decision

has been reached, the surgeon must back
his judgment by immediate operation, con-
sistent with sound surgical principles.

Evidences of severe injury are by no
means always apparent immediately follow-
ing the accident. Trauma may result to one
or more portions of the gut, producing ne-
crosis and sloughing some days later. Slight
injuries to the solid organs may later re-
sult in abscesses. These, of course, are dealt
with as they become apparent. Holes in the
gut must be repaired or treated conserva-
tively as the conditions indicate, and ab-
scesses must be drained after they are well
walled off.

The electrolytic fluids, of course, should
be used freely, consistent with our estab-
lished knowledge of the body’s needs. The
sulfonamides, the great gift to medicine and
surgery, should be used locally, parenteral-
ly or per os freely. The recent increase in
the manufacture of penicillin has enabled
us to give our patients the benefits of this
great life saving addition to our medical
armanentarium.

The probable point or points of injury
are, of course, always purely speculative,
but having determined the place on the ab-
dominal surface where the blow has been
struck, one should with a limited degree of
certainty be prepared to deal with specific
organs. If the blow is over the upper ab-
dominal cavity, the liver, spleen, pancreas,
stomach, duodenum or transverse colon, one
or more may be injured. A blow over the
bladded may rupture that organ, while the
intestines may be involved by any blow any-
where on the abdominal surface.

In the first twelve hours following in-
jury, unless there is present the usual signs

384

Bgdenheimer — Ruptured Intestines

and symptoms of severe hemorrhage, the
surgical decision is very difficult, if not
impossible. One is justified in “watchful
waiting” and at the same time using all
standard laboratory aids in addition to clin-
ical observations. A board-like abdomen,
unrelieved by opiates; distention, increase
in the leukocytes with the well known dif-
ferential count usually observed in infec-
tions, and finally air under one or both
leaves of the diaphragm when the picture
is taken in the sitting position, are enough
evidences to justify the opening of the ab-
dominal cavity.

The absence of signs of surface trauma
such as swelling, ecchymosis or even skin
tenderness, does not rule out by any means
the possibility of a ruptured viscus. The
full force of the blow can be transmitted to
the intestines or one or more of the abdom-
inal organs, and the skin even during con-
valescence may never have any signs of
trauma.

CASE REPORT

A cabinet maker, 49 years old, a German Jewish
refugee, while cutting a block of wood with a rip
saw, was struck in the left lower abdomen when
the saw broke. He was removed to his home where
morphine was administered because of the intense
pain from which he was suffering. He was later
taken to the Schumpert Sanitarium where the
opiate was repeated every four hours. An ice bag
was also placed over the seat of injury. Twelve
hours after the injury there was still no relief
from pain. The abdomen was tender and board-
like on palpation when the patient was seen short-
ly after the accident; now it was distended. There
was no evidence of injury on the skin surface.
There were no abrasions, no hemorrhages, no
marks of any kind discernible even eighteen hour.;
after the injury, nor was there ever any evidence
of trauma to the skin at any time following the
injury. The white count fourteen hours after the
injury was 19,500 with 93 per cent polys. An
x-ray showed no evidence of fracture of the pelvic
bone, but there were considerable quantities of air
under both leaves of the diaphragm when the x-ray
was taken with the patient in a sitting position.
These findings confirmed our suspicions of rup-
tured intestines.

A midline infra-umbilical incision was made.
The abdominal cavity contained cloudy purulent
fluid with the usual early inflammatory changes
found in acute peritonitis. A single opening into
the bowel, the circumference of a lead pencil, and
straight longitudinal tears on either side of the
opening through the serous membrane only, each

about IV2 cm. in length, were found in the upper
portion of the ileum. No other injuries were found
after a careful examination of the abdominal con-
tents. The opening was closed by a catgut purse-
string suture and reinforced with a second line of
interrupted sutures. The serous membrane tears
were sutured with interrupted catgut sutures. The
abdomen was closed without drainage after 10
grams of sulfanilamide were scattered throughout
the abdominal cavity. The condition of the pa-
tient during the fifty-five minutes of the operation
was excellent. The pulse varied between 94 and
100 per minute. At the beginning of the opera-
tion the blood pressure was 132/80. The patient
left the operating table with a blood pressure of
150/90. Shortly after the patient was returned
to his room 500 c.c. of citrated blood were admin-
istered. A continuous intravenous drip of 10 per
cent saline and/or glucose was given, and every
four hours 15 grains of sulfanilamide in 125 c.c.
of distilled water were allowed to flow into the
vein by using the same double bottle method used
in administering citrated blood. Wangensteen suc-
tion was also instituted and a colon tube inserted
from time to time in accordance with the judgment
of the nurse on duty.

Although his general physical condition con-
tinued satisfactory, on the third day of the post-
operative treatment he began to grow restless, in-
coherent in speech and finally become so violent
that he had to be restrained. In spite of the watch-
ful care of the nurse he got out of bed on the
fourth day. Under forceful restraint four grains
of sodium amytal wex-e given by vein to quiet him.
Six hours later 7% grains were administered by
vein, as opiates and hyoscine only made him more
violent. At this time the urine showed 4+ albu-
min with a few hyaline, finely granular casts and
red blood cells, with a trace of sugar. The blood
showed a 10 mg. per 100 c.c. concentration of sul-
fanilamide. NPN was 56 mg. per 100 c.c. blood.
As the cause of the delirium was apparent (the
sulfanilamide concentration) the drug was discon-
tinued. There was always an adequate amount of
urine passed and the specific gravity was satis-
factory throughout. His mania grew less, but
was not entirely abated until the tenth day follow-
ing the operation. At this time the sulfanilamide
had entirely disappeared from the blood, the urine
was negative and the bowels, which had moved
from enema on the sixth day, were moving regu-
larly. There was no abdominal distention at this
time. A slight skin infection healed readily.

An interesting and unusual situation occurred
during the height of the delirium. One night he
called repeatedly, “Police, police.” When I was
contacted by the nurse, I instructed her to call
the police. As soon as two police appeared at his
bedside, he became quiet and dropped off to sleep.
After he had recovered he remembered the inci-
dent clearly and explained that he thought he

Steiner — Antenatal Thrombophlebitis

385

was in a concentration camp in Germany and was
being tortured by the Gestapo.

For some months after his release from the
Sanitarium he complained of abdominal pain,
which eventually disappeared. He is now back
at work at his previous occupation.

O

ASEPTIC ANTENATAL THROMBOPH-
LEBITIS (PHLEBOTHROMBOSIS)

MELVIN D. STEINER, M. D.f
New Orleans

Antenatal thrombophlebitis is apparently
a very rare condition, in contrast to puer-
peral thrombophlebitis (phlegmasia alba
dolens), which is by no means infrequent.
Westmann1 sets the relative incidences at
0.1 and 5 per cent, but states no basis for
the statistics.

There is almost nothing in the literature
on the subject, and three of the 10 cases
collected by Goldsborough,2 when he report-
ed an additional personal fatal case in 1904,
are inadequately described. The disease is
not mentioned in most textbooks of obstet-
rics. Stander,3 in the 1941 edition of Wil-
liams’ Obstetrics, refers to Goldsborough’s
report and adds, “Since then we have seen
several additional cases,” but supplies no
details. Kahr,4 in 1937, reported four cases
of thrombosis of the deep veins of the lower
extremities (as well as three instances of
superficial thrombosis), and Maxwell5 re-
ported another case in 1943. I have no
doubt that additional cases have occurred
and have not been reported, and also that
other cases have been reported but, as so
often happens, cannot be identified by title
when the literature is searched. At any rate,
as matters now stand, the case I am report-
ing herewith seems to bring to 17 the num-
ber of formally reported cases, excluding
the “several” cases mentioned but not de-
scribed by Stander.

CASE REPORT

Mrs. W. R. P., a white primipara 36 years of
age, was first seen during an uncomplicated,
afebrile abortion at the end of the second month
of a pregnancy which had been without special in-

fFrom the Depa'rtments of Obstetrics and
Gynecology of the Tulane University of Louisiana
School of Medicine.

cident. Periods were missed for the next two
months, but pain in the lower abdomen was present
during the time menstruation would normally have
occurred. Several examinations revealed a pro-
lapsed and tender left ovary. Improvement oc-
curred under a regimen of daily hot douches.

The patient menstruated for the first time since
the abortion on August 20, 1942, but missed the
September period. On the approximate date of
the October period she bled slightly and passed a
small clot. Although there was no recurrence of
the bleeding she was kept in bed until November
24, 1942, that is, until after the date of the No-
vember period.

Her previous history contained no significant in-
cident, and physical and routine laboratory ex-
aminations at this time revealed no abnormalities.

November 25, 1942, the day after the patient
was first permitted to be ambulatory, she expe-
rienced pain in the calf and muscles of the left leg.
She had no fever then or at any other time during
the illnes. Examination revealed tenderness and
redness along the entire course of the left saphe-
nous vein, with pitting edema of the leg and thigh.
A diagnosis of aseptic thrombophlebitis (phleboth-
rombosis) of the internal saphenous vein was made,
and conservative therapy, including bed rest, eleva-
tion of the extremity, the application of heat and of
an ace bandage, and a course of sulfathiazole, was
instituted under the direction of Dr. Sidney Cop-
land. When this regimen produced no improve-
ment, sympathetic lumbar block with 1 per cent
novocain was carried out on December 11, 1942.
The pain in the limb was promptly relieved and
the edema soon afterward disappeared. The pa-
tient was permitted out of bed with an elastic
stocking on Decmeber 23. At this tme she weighed
134 pounds and the blood pressure was 110/70.

Pain in the calf and muscles of the right leg
was experienced on February 14, 1943, and, as dur-
ing the attack in the other leg, failed to respond
to conservative therapy. Lumbar sympathetic block
on this side was therefore carried out on February
26, again with prompt relief of pain and edema.
Forty-eight hours after th& operation she had a
sudden sharp pain in the right thorax and pre-
sented the typical picture of an aseptic pulmonary
infarct. She responded slowly to conservative ther-
apy, including strapping of the chest, and was
permitted to be ambulatory by March 13, 1943.
From that time until the date of writing (October,
1944) she has had no recurrence of the vascular
disturbance.

Pregnancy progressed smoothly until March 17,
1943; then bilateral edema of both lower extremi-
ties appeared and became slowly progressive until
April 14, when edema of the face was also ob-
served. The blood pressure, which had previously
been stationary at 110/70, was now 116/76. The
weight was 152 pounds. The urine contained no

386

Steiner — Antenatal Thrombophlebitis

albumin or other abnormal constituents, A high-
protein, salt-free diet was instituted.

During the next two weeks the edema of the
legs did not progress but also it did not regress.
The blood pressure remained at the same level.
Pelvic examination on April 28 revealed the pres-
entation to be vertex and the position ROA. The
cervix was soft but not dilated. The child seemed
small. Fetal heart tones of good quality were heard
in the left lower quadrant. The fluid intake on this
date was four and a half quarts and the output
two and three-quarter quarts. The regimen already
instituted was continued.

May 5, 1943, the patient weighed 154% pounds
and her blood pressure had risen to 130/90. The
urine contained a trace of albumin. On the follow-
ing day she complained of severe headache, her
blood pressure rose to 170/100, and the urine con-
tained 3 plus albumin.

She was at once hospitalized and was placed on
a strict toxemia regimen. At the end of 48 hours
her clinical condition was essentially the same as
on admission, but the urinary albumin had not de-
creased and her blood pressure had risen to 200/
100. Labor was therefore induced without delay by
the serial administration of small doses of pitocin.
Pains ensued promptly, and delivery of a five-
pound male child was effected without difficulty
1 1 hours later by low forceps and episiotomy.
Hemorrhage was minimal. When morphine gr. 1/4
was administered after the delivery of the child,
the patient’s respirations fell promptly to eight per
minute, but rose to the normal level after the ad-
ministration of oxygen.

The child was normal in all respects except for
a slight hypospadias. Soon after birth, however, he
became cyanotic, and attacks of cyanosis persisted
for almost a week and were sometimes alarming.
Feeding also presented difficulties, but eventually
an appropriate formula was found and he was dis-
charged from the hospital in good condition, after
a satisfactory gain in weight.

The mother’s convalescence was smooth except
for the development of a moderate lymphangitis
and phlebitis of the left upper extremity, clearly
originating in chemical irritation following infus-
ion. When she left the hospital on the fifteenth
postpartal day her blood pressure was 120/30, she
weighed 134% pounds, and the urine was free of
albumin. A moderate erosion of the cervix was
treated by cauterization several times in the next
three months.

The patient has been observed at intervals to
date (October, 1944) and has presented no abnor-
mality of any sort, including, as already stated, no
recurrence of the vascular abnormalities.

To complete the history, it should be stated that
laboratory examinations threw no light on this
case. The blood serologic reactions were negative.
Complete hematologic study three weeks before de-
livery revealed the following data: Coagulation

time two minutes 45 seconds. Bleeding time four
minutes 10 seconds. Clot reaction good. Red blood
cells 4,580,000, white blood cells 9,850 per cu. mm.
Hemoglobin 80 per cent (12.5 gm.). The differen-
tial values were within normal range except for a
slight shift to the left of neutrophiles. The pro-
thrombin concentration was 115 per cent.

COMMENT

The number of reported cases (17 in-
cluding the one reported herewith) is too
small for significant analysis, but certain
data derived from them might be men-
tioned. Both unilateral and bilateral in-
volvement occurred and both the saphenous
and femoral veins, with their branches, were
affected. Fever was seldom a part of the
picture, and the diagnosis of aseptic throm-
bophlebitis (phlebothrombosis) was there-
fore usually warranted, as in my personal
case. Recovery was usually complete,
though all patients did not go to term, but
Goldsborough’s case ended fatally, and
Bacon’s6 patient, one of the few with fever,
continued to suffer from swelling and ten-
derness in the leg when she began to walk
five weeks after delivery and about 60 days
after the onset of phlebitis.

The case reported herewith differs from
most reported cases in the early onset of
the complication, at the end of the third
month of pregnancy, when the uterus, al-
though enlarged, is not yet large enough to
cause much pressure on the pelvic struc-
tures. The patient presented no evidence
of focal infection or of any other abnormal-
ity which might have been related to the
vascular condition. The toxemia, which is
listed as a possible factor in some of the re-
ported cases, occurred about four months
after the first attack of thrombophlebitis
and more than a month after the recurrent
attack in the other leg, which seems to rule
it out as a cause. Indeed, the only factor
in the whole history which can be related
to the development of thrombophlebitis is
the prolonged period of rest in bed, to avert
a threatened abortion, which terminated ex-
actly 24 hours before the vascular condition
first became evident. Stasis due to pro-
longed bed rest is, of course, an important
factor in the development of postoperative
thrombosis and thrombophlebitis.

Steiner — Antenatal Thrombophlebitis

387

In most of the reported cases either there
is no evident etiologic factor, or the cause
advanced is applicable only to the special
case or is entirely unreasonable. Browne
(cited by Maxwell) mentioned varicose
veins as a predisposing cause, and they fre-
quently are responsible for superficial
venous thromboses in pregnant women. But
many pregnant women, as in this case, do
not present varicosities, and the explana-
tion is therefore not generally applicable.
In Maxwell’s own case the only variation
from the usual was the fact that the preg-
nancy was a twin-gestation, but the author
does not seem to regard this as an explana-
tion. The patient had a bilateral involve-
ment of the great saphenous vein and its
lateral branches 39 days before delivery,
which occurred 14 days before the expected
date ; recovery was complete before she left
the hospital.

Bacon’s patient, already mentioned, de-
veloped uterine contractions soon after a
fall on the ice in the thirty-third week of
pregnancy, and 10 days later developed
fever and great pain and edema of the left
leg. The author’s suggestion that “the long-
continued uterine contractions may have
dislodged placental masses that formed
rudimentary emboli, or perhaps altered the
blood composition,” is a concept as specula-
tive as it is generally inapplicable, but it
was advanced in 1903. Westmann states
that it is “not a mere hypothesis” to assume
that women who incline to varicose veins,
thrombosis and embolism must be consid-
ered as possessing inferior cardiovascular
systems, most probably the result of en-
docrine insufficiency, but advances no proof
for the theory and reports no cases of ante-
natal thrombophlebitis.

Veal and Hussey,7 whose discussion is
also general, grant the responsibility of
such factors as the size and position of the
uterus, the length and mobility of the sup-
porting ligaments, the size of the pelvis,
and the tone and development of the ab-
dominal musculature in the production of
abnormalities of the venous circulation in
the lower extremities during pregnancy.
After a study of popliteal venous pressures

in pregnant women during exercise they
concluded that postural dependent edema
and varicose veins of the lower extremities
are due to localized obstruction of the deep
veins. This theory explains individual
cases of this sort, and furnishes the only
reasonable explanation for unilateral edema
and varicosities. It is quite possible that
localized obstruction of the deep veins may
prove the explanation of antenatal throm-
bophlebitis, though I am not aware that
any case has yet been studied from this
point of view.

In Goldsborough’s case the etiologic fac-
tor seems clearcut. The patient, a 29 year
old working woman, in an endeavor to con-
ceal her pregnant state (it should be re-
membered that this case was reported in
1904), wore a very tight, heavily boned
corset. She was first seen in the seventh
month of gestation, a week after the devel-
opment of edema and swelling of the left
leg and four days after the development of
almost continuous vomiting. The left leg
presented an enormous symmetrical pitting
edema extending from the toes to the groin,
and there was considerable abdominal dis-
tention. The uterus was displaced to the
left. Urinalysis was essentially negative.

The patient’s vomiting could not be con-
trolled by any method then available and
bag induction of labor was therefore car-
ried out. The bag burst 10 hours after its
introduction, but the patient went into la-
bor, which was eventually terminated by
manual dilatation of the cervix, version and
extraction performed forcibly and with
much difficulty in a tetanically contracted
uterus, and manual removal of the placenta.
The child was born dead, and the patient,
who was badly shocked and had lost a large
amount of blood, died 15 hours after de-
livery.

Postmortem examination showed marked
degeneration of the liver cells and of the
kidneys, especially in the convoluted tub-
ules. The patient had had a large amount
of chloroform, which perhaps explains these
findings, on the basis of the liver-kidney
syndrome.

388

Steiner — Antenatal Thrombophlebitis

The lumen of the left common iliac vein
was completely occluded at the point of its
crossing by the right common iliac artery.
The vessel from this point downward was
filled with a thrombosed mass which ex-
tended into the external iliac vein and
thence into the femoral and saphenous
veins; above the point of compression it
was perfectly normal. Histologic examina-
tion showed practically no change in the
vessel walls except for the absence of the
endothelial lining. Signs of marked inflam-
matory reaction were lacking. The entire
lumen was merely filled by blood clot firm-
ly adherent to the wall. Cultures from the
heart blood and from the thrombus were
sterile, and bacteria could not be demon-
strated by any method.

The author speculated, with complete
reasonableness, that the origin of the
thrombosis in this case was pressure on the
retroperitoneal structures by the patient’s
heavy corset. As the enlarging uterus was
forced backward and downward against
the bodies of the lumbar vertebrae and the
structures in front of them, it interfered
with the return of the blood from the lower
extremities, particularly at the crossing of
the right iliac artery by the left common
iliac vein. As the pressure increased, the
iliac vein eventually became compressed be-
tween the artery in front and the verte-
bral column behind, with the result that the
lumen became completely obliterated, with
terminal stagnation, coagulation and throm-
bosis. The explanation is adequate, but
the case is unique.

The cause of thrombophlebitis in non-
pregnant subjects is still a matter of dis-
pute, and it is scarcely surprising that no
universal cause has been advanced for the
small group of cases reported in pregnant
women. The relief obtained by lumbar
sympathetic block in the case reported here-
with supports the concept of a possible
vasospastic background. It is also possible
that this particular case (and perhaps other
cases) is an instance of so-called primary
idiopathic thrombophlebitis of the recur-
rent type, which was formerly called throm-
bophlebitis migrans. The subject was thor-

oughly reviewed by Barker8 in 1936. In a
report of 79 cases observed at the Mayo
Clinic, 40 of which were of the recurrent
type, acute infarction occurred in 12 in-
stances, as it did in my personal case, and
five patients in the group eventually died
of pulmonary embolism.

Although the only fatality in the reported
instances of antenatal thrombophlebitis
seems to be Goldsborough’s case, in which
the circumstances are obviously unique, it is
well to emphasize that this is always a po-
tentially serious condition. Labor, as sev-
eral authors have pointed out, may provide
sufficient impetus to cause liberation of a
thrombus in the affected vein or veins,
though, happily this does not seem to have
occurred in any of the reported cases. The
possibility, however, should be borne in
mind, and all manipulations in such patients
should be extremely cautious, with the rec-
ollection that fatal pulmonary embolism
may be the end-result of carelessness in
this regard.

SUMMARY

A case of aseptic antenatal thrombo-
phlebitis (phlebothrombosis) is reported,
and is apparently the seventeenth to be re-
corded with any detail in the literature. No
universally applicable explanation has yet
been advanced for the condition. Although
only one of the recorded cases seems to have
terminated fatally, the complication is po-
tentially serious and all manipulations in
such patients should be very gentle.

REFERENCES

1. Westman, Stephen K. : Thrombophlebitis in obstetrics
and gynecology, Lancet, 2 :421, 1936.

2. Goldsborough, F. C. : Thrombosis of the internal iliac
vein (luring pregnancy, John Ilopkins IIosp. Bull., 15 :193,
1904.

3. Stancher, H. J. : Williams Obstetrics. A Textbook for
the Use of Students and Practitioners. Ed. 8. New York
and London, 1941, D. Apple ton-Century Company Incor-
porated.

4. Kahr, H. : Uber Thrombophlebitic in der Schwanger-
scliaft im besonderen Ilonblick auf die Geburtsleitung,
Wien. med. Wehnschr., 87 :5G4, 1937.

5. Maxwell. J. 'P. : Antenatal thrombophlebitis, J. Obst.
& Gynaec. Brit. Emp., 50 :299, 1943.

0. Bacon, C. S. : Phlegmasia alba dolens during preg-
nancy. Am. J. Obst. & Dis. Women & Child., 48 :518, 1903.

7. Veal, J. It., and Ilussey, H. H. : The venous circula-
tion in the lower extremities during pregnancy, Surg.,
Gynec. & Obst., 72:841, 1941.

S. Barker, X. W. : Primary idiopathic thrombophlebitis,
Arch. Int. Med., 58:147, 1936.

Warren

■Headache

389

CERTAIN ETIOLOGIC FACTORS CON-
CERNED WITH HEADACHE*

EDGAR WARREN, M. D.f
New Orleans

The number of etiologic factors produc-
tive of the prevalent symptom, headache,
is infinite and the real cause is difficult to
determine. Consequently, specific treat-
ment remains a problem. Fortunately, in
most instances, no treatment is necessary
or palliative measures are sufficient to re-
lieve the discomfort. However, the patient
with the chief complaint of headache offers
a distinct challenge to the diagnostician’s
acumen. Of some importance in the de-
termination of the cause of cephalalgia is
an understanding of the nerve supply to the
head and the known mechanisms by which
head pain is produced. Therefore, these
and other points will be briefly discussed
as a possible method of approach in the de-
termination of the cause of headache.

NERVES INVOLVED IN HEAD PAINS AND1 THEIR
DISTRIBUTION

Extracranially, from all areas of the head
anterior to a line drawn vertically in front
of the ears, pain is mediated by way of the
three branches of the fifth cranial nerve.
Behind this line sensation is transmitted by
the upper three cervical nerves. In addi-
tion, the ninth and tenth cranial nerves are
supposed to have some sensory terminations
in the external auditory canal.

In relation to head pain and headaches in
general the eyes should be considered as a
possible factor. The structures of the eyes
are innervated by the ophthalmic division
of the trigeminal nerve. Sensation originat-
ing in the cornea is localized accurately.
However, it is more difficult to determine
the source of pain when it is within the
deeper structures. It has been shown1 that
traction on the ocular muscles and ciliary
body produces pain deep within the orbit
which may radiate over the entire distribu-
tion of the first branch of the trigeminal
nerve. Induced imbalance of the eixtra-
ocular muscles, if prolonged, will cause ner-

tFrom the Section on Internal Medicine, Ochsner
Clinic, New Orleans.

vous tension followed by headache. This
headache is associated with abnormal myo-
grams of the scalp and posterior cervical
muscles. As a matter of fact, any inflam-
matory condition of the eyes, glaucoma, as-
tigmatism, hypermetropia, or abnormal ac-
commodation, may in a similar fashion pro-
duce tension in the muscles of the head and
neck with subsequent headache. On the
other hand, myopia does not often produce
pain or headache of this type.

Another extracranial source of headache
is the nasal cavity. It has been found that
the sinus mucosa has a low order of pain
sensitivity.2 Stimulation of these mucous
membranes by various means never causes
pain in the neck or back of the head. In
general, severe pain occurs only with in-
flammation and engorgement of the tur-
binates, sinus ostia, nasofrontal duct, and
superior nasal spaces. It should be noted
further that pain originating from the na-
sal structures involves primarily the distri-
bution of the maxillary or ophthalmic
branch of the fifth cranial nerve, which,
under certain conditions, may spread to
other parts of the head.

Within the cranial vault, pain originat-
ing above the cerebral tentorium is medi-
ated over the ophthalmic branch of the tri-
geminal nerve ; the other two divisions of
the fifth cranial nerve have no known in-
tracranial terminations. Below the tento-
rium, pain sensation is transmitted along
branches of the ninth and tenth cranial
nerves and of the second and third cervical
nerves. From no part of the head is there
evidence to indicate that afferent fibers of
the sympathetic system transmit pain or
other sensations arising in consciousness.

Furthermore, all structures external to
the bone of the cranial vault, including the
vascular system, are sensitive in varying
degrees3. The bone, the pia-arachnoid, the
brain substance itself, the ventricular walls
and the choroid plexus are, however, insen-
sitive to painful stimuli. The dura mater
is only painful when stimulated adjacent to
the main arteries or upon extreme pressure.
A few of the venous sinuses and connecting
extremities of cerebral veins are likewise

390

Warren — Headache

pain sensitive. The arteries in forming the
circle of Willis and for about one-third of
their length distally give rise to pain. The
middle meningeal artery is extremely sen-
sitive to pain throughout most of its course.

In brief, it is known that extracranial
pain is usually well localized and similar in
character to cutaneous pain elsewhere in
the body. However, pain originating extra-
craniallv from the eyes and sinuses assumes
the characteristics of visceral pain else-
where and is of a disagreeable nature, radi-
ates widely and is difficult to localize with
accuracy. The same remarks apply to pain
originating within the cranial vault. Thus,
it is well to recall that intracranial disease
in the back of the head may refer pain to
the frontal areas due to the prolongation
backwards of a branch of the ophthalmic
division of the fifth nerve.

MECHANISMS BV WHICH HEAD PAIN IS PRODUCED

Several mechanisms have been demon-
strated by which intracranial pain is pro-
duced4. First of all, there may be traction
or stretch placed upon the dura mater or
vascular system as a cause of pain. Thus,
after removal of cerebrospinal fluid, stretch
is undoubtedly placed on the cerebral veins
as they enter the sagittal and other venous
sinuses. Proof of this mechanism is shown
by the relief of such pain when the fluid
volume has been restored or the head has
been tilted downward to one side. By both
of these means traction is reduced. Simi-
larly, in expanding lesions such as tumors,
hematomas, aneurysms, hemorrhage or
edema, stretch may be applied to the ar-
teries at the base of the brain or to the
middle meningeal artery with consequent
stimulation of pain sensitive structures.

A second obvious mechanism for head
pain is direct pressure of a lesion upon a
nerve. However, this is probably of little
importance until late in the course of a dis-
ease because of the capacity of the brain to
shift its position slowly in a fluid matrix.
A third incitement for pain is direct stimu-
lation of pain sensitive endings by bacterial
agents or their products and possibly other
toxins.

A fourth mechanism for inducing head-
ache intracranially is concerned with ab-
normal dilatation or loss of tone of the sev-
eral pain sensitive arteries. Several fac-
tors need to be considered for a partial un-
derstanding of this phenomenon. It should
be noted that arterial dilatation elsewhere
in the body is seldom painful. This differ-
ence may possibly be explained on the basis
of the more rigid confines of the scalp and
cranial cavity. More germane to an under-
standing of this mechanism is the relation-
ship of the blood pressure and the cerebro-
spinal fluid pressure to each other and to
the tone of the arterial walls. These rela-
tionships have recently been vividly demon-
strated by several investigators4’ 5 who em-
ployed strong vasodilating drugs, such as
histamine or nitrates, experimentally.

The intravenous administration of hista-
mine causes rapid dilatation of the arterioles
of the body, including those of the cranium.
Headache does not develop concomitantly
with this widespread loss of tone. At first
there is an abrupt decrease of the systemic
blood pressure and an associated rise of the
cerebrospinal fluid pressure. The latter is
apparently sufficient to maintain some ar-
terial tone. Shortly afterward, however,
the blood pressure rises rapidly to its origi-
nal level, as the systemic arteries regain
their tone, which they do long before those
of the cerebral circulation. As the systemic
blood pressure returns to its previous level,
the cerebrospinal fluid pressure rapidly de-
clines; this removes this support to the al-
ready distended cerebral arteries. There-
after, with each wave of the pulse, the
typical throbbing headache is experienced
and gradually declines in intensity over a
period of six to eight minutes as the cere-
bral arteries gradually regain their normal
tone. A similar sequence of events is asso-
ciated with the headache induced by nitro-
glycerin.

While on the subject of headaches origi-
nating from vascular structures, it might
be well here to discuss briefly a few points
about migraine and hypertensive headaches
not associated with heart failure or en-
cephalopathy. These headaiihea are Like-

Warren

■Headache

391

wise due to arterial dilatation4, but the ar-
teries most prominently involved are extra-
cranial, that is, the branches of the external
carotid artery. Furthermore, migraine and
hypertensive headaches are not affected by
changes of the blood pressure or the cere-
brospinal fluid pressure. As a matter of
fact, it has been repeatedly demonstrated
that the administration of ergotamine tar-
trate will abort or relieve the headaches of
migraine and hypertension. In so doing,
this drug acts specifically upon the
branches of the external carotid arteries
and at the same time induces a further ris-;
in blood pressure.

Although several factors and mechanisms
concerned with headaches have been dis-
cussed, it would be misleading to give the
impression that the site or nature of or-
ganic disease can be readily diagnosed in
the light of these concepts. Headaches of
organic origin are more usually a combina-
tion of two or more of these mechanisms.

In the case of expanding lesions0, such as
brain tumors, aneurysms or hematomas, the
character of the pain varies widely even in
the same person. Sometimes, it may be
throbbing and therefore seemingly due to
vascular distention as a localized process.
Again, it may be intensified by certain
movements of the head ; this suggests a
traction origin. On other occasions the
pain may be sharp and lancinating which
may be due to direct pressure on a nerve
trunk.

It is the general impression that the in-
creased cerebrospinal fluid pressure usually
associated with expanding lesions is the
cause of the concomitant headache. Statis-
tics refuting this statement have been re-
ported.0 Of 65 cases of brain tumor with
headache. 49 had increased cerebrospinal
fluid pressure. In another series7 of 121
cases, 63 per cent of the patients had pres-
sure over 200 mm. of water and many of
these had no headache. Furthermore, as
noted previously,4' 8 many headaches of vas-
cular origin may be relieved by increasing
the cerebrospinal fluid pressure. However,
if there is a block to the flow of spinal
fluid, the incidence of headaches becomes

practically 100 per cent. The mechanism
of headaches in such cases is clearly that of
traction.

The localization of pain associated with
brain tumors or other expanding lesions is
not too helpful in diagnosing the site of the
neoplasm.0 Frontal pain is experienced in
95 per cent of patients with supratentorial
tumors; 75 per cent of patients with infra-
tentorial tumors likewise have frontal pain.
Pain and spasm in the back of the neck
were found in 22 per cent of patients with
supratentorial tumors and 45 per cent with
infratentorial growths. Of 66 patients with
unilateral headaches, the tumor was found
on the opposite side in 15 instances. It
seems obvious, therefore, that in the diag-
nosis of a growing lesion within the cranium
the facts concerning the pain are of little
help in general.

Another type of headache is that occur-
ring subsequent to brain concussion. The
differentiation between those of purely or-
ganic and those of psychogenic origin seems
to be a matter of personal opinion in most
instances. Denny-Brown9, in experiments
on animals, showed that during the period
of unconsciousness, characteristic general-
ized patterns appeared in the electro-en-
cephalogram, even though microscopic evi-
dence of damaged tissue was seldom found
at autopsy. Persistent deviations from the
normal patterns may eventually be in-
terpreted as a specific sign of post-con-
cussional pathologic condition.

One of the characteristics of the post-
concussional synd/rome is the paucity of
findings pointing to a known organic lesion.
The incidence of disability varies from 20
to 80 per cent. In the presence of severe
brain damage, it is noteworthy that com-
parable symptoms develop in only 10 per
cent of cases. It is apparent that under-
lying the development of the post-concus-
sional syndrome, there is a preceding his-
tory of anxiety and emotional instability
associated with poor physical development
and vasomotor over-reaction. All symp-
toms and signs of the various headache
mechanisms are found in this syndrome.
The pain is often made worse by excitement,

392

Arosemena — Treatment of Amebiasis

fatigue, exertion, changes in the weather,
alcohol and various movements of the head.
It is frequently accompanied by dizziness,
nausea a(nd vomiting. Diagnosis, there-
fore, still rests on the exclusion of other
factors in conjunction with a thorough
history, physical examination and determi-
nation of the psychic make-up.

Before concluding, another factor which
seems important in the approach to the de-
termination of the cause of headaches
should be mentioned. This is the time of
onset of the headache within the 24 hour
period. Headache, associated with the fol-
lowing conditions, is prone to awaken the
patient or is present when he arises in the
morning: (1) expanding intracranial le-
sion; (2) maxillary or frontal sinusitis;
(3) hypertension with early renal failure
or encephalopathy and perhaps other condi-
tions in which edema or dehydration of the
brain occurs, such as in a “hangover,” in
hyperinsulinism or after the excessive ad-
ministration of hypnotics; (4) cervical ar-
thritis associated with strained positions in
sleep and (5) histaminic cephalalgia.

Headaches occurring late in the after-
noon or evening may be caused by various
factors. The involvement of the ethmoid
and the sphenoid sinuses is thought to pro-
duce headache late in the day. Fatigue
from any cause, more specifically that in-
duced by diseases of the eyes, toxins, such
as tobacco and, most important, nervous
tension, may produce headaches which
seem to occur more frequently as the day
progresses. Headaches of these origins,
excluding migraine, are more characteris-
tically located either in the vertex of the
skull, which is a site of pain seldom referred
to in organic disease, or in the back of the
head and neck. The latter headache or pain
is caused by persistent tension of the
muscles of the neck and scalp associated
with abnormal myograms.10 Palpation of
this area reveals definite spasticity of the
cervical muscles, and here it must be re-
called that with intracranial expanding le-
sions, as well as with arthritis of the cer-
vical spine, there may be spasticity of the
same group of muscles.

CONCLUSION

In the determination of the cause of head-
ache the essential fact to be remembered is
that headache is merely a symptom which,
in most instances, gives little information
as to its exciting cause. The benign or ma-
lignant stimulant of the pain sensitive
structures can rarely be differentiated by
the character or distribution of the pain it-
self. Nor does a knowledge of the pain
mechanism concerned always provide a spe-
cific etiologic diagnosis. To serve the pa-
tient faithfully, therefore, a thorough eval-
uation of his physical and mental condition
is essential.

REFERENCES

1. Eckliardt, L. B.. McLean, J. M., and Goodell, II. : Ex-
perimental studies on headache: the genesis of pain from
the eye, Nerv. & Ment. Dis. Proc., 23 : 209, 1943.

2. McAuliffe, G. W„ Goodell, H„ and Wolff, H. G. :
Experimental studies on headache : pain from the nasal
and paranasal structures, Nerv. & Ment. L>is. Proc-., 23 :
185, 1943.

3. Ray, B. S., and Wolff, H. G. : Experimental studies
on headache : pain sensitive structures of the head and
their significance in headache, Arch. Surg., 41 :813. 1940.

4. Schumacher, G. A., and Wolff, H. G. : Experimental
studies ; contrast of histamine headache with headache of
migraine and that associated with hypertension ; contrast
of vascular mechanisms in pre-headache and in headache
phenomena of migraine, Arch. Neurol. & Psyehiat., 45 :199,
1941.

5. Pickering, G. W. : Experimental observations on head-
ache. Brit. M. J.. 1 :907, 1939.

0. Kunkle, E. €., Ray, B. S., and Wolff, H. G. : Studies
on headache ; the mechanisms and significance of head-
aches associated with brain tumor, Bull. New York Acad.
Med., 18:400. 1942.

7. Northfield, Ii. W. C. : Some observations on headache
(Hunterian Lecture, abridged), Brain, 61 :133, 1938.

S. Kunkle, E. C., Ray. B. ,S.. and Wolff, H. G. : Experi-
mental studies on headache : analysis of headache associ-
ated with changes in intracranial pressure. Arch. Neurol.
& Psyehiat., 49 :323, 1943.

9. Denny-Brown. D. : Sequelae of war head injuries,
New England J. M., 227 : 7 7 1 , 813, 1942.

10. Simons, D. J.. Day, E., Goodell, H., and Wolff, H. G. :
Experimental studies on headache ; muscles of scalp and
neck as sources of pain. Nerv. & Ment. Dis. Proc., 23 :
22S, 1943.

O

TREATMENT OF AMEBIASIS

JUAN AROSEMENA, M.D.

New Orleans

definition

A-mebiasis is defined as the state of being
infected with the protozoan organism
known as Endamoeba histolytica and the
term includes all of the clinical pictures
caused by the invasion of this organism.
Amebiasis embraces the signs and symp-
toms in mild infections in which vague

Arosemena — Treatment of Amebiasis

393

gastrointestinal symptomatology is present ;
those present accompanied by severe en-
teritis; those present in acute amebic dy-
sentery; and those present in complications
from invasion of the liver, lungs, brain,
skin or other organs by Endamoeba his-
tolytica, as well as carrier states.

HISTORY

The first accurate description of the
causative organism we owe to Losch who
in 1875 in St. Petersburg, Russia, studied
an undoubted case of amebic dysentery with
relapses and found the organism in the
stool. He named the organism Amoeba
coli. Shaudinn in 1903 accepted the name
for the genus previously proposed by Casa-
grandi, but named his pathogenic species
Endamoeba histolytica and the non-patho-
genic Endamoeba coli. Sir William Osier
was the first person in the United States to
demonstrate the amebae in a case of dy-
sentery and liver abscess.

DISTRIBUTION

Amebiasis is world-wide in distribution.
It can no longer be considered a tropical
disease. In some districts in the temperate
zone where sanitary conditions are poor,
the incidence may be almost as high as in
tropical countries. In the United States it
has been conservatively estimated that from
5 to 10 per cent of the population harbor
the organism. Since only a relatively small
percentage of infected patients suffer from
the disease, the number of asymptomatic
carriers is exceedinly large.

COMPLICATIONS AND SEQUELS

Amebic abscess of the liver is the most
important and most frequent complication
of amebiasis, and usually occurs after at-
tacks of diarrhea or dysentery, but may oc-
cur in a carrier who has never had such at-
tacks. Amebic abscess, abscess of the lung,
brain, spleen and other organs have been
repeatedly reported. Perforation of ame-
bic ulcer of the intestine sometimes occurs
with a resulting peritonitis, and the erosion
of a blood vessel by such ulcerations with
the consequent production of fatal hem-
orrhage from the bowel has been reported
by several investigators.

The most common sequels of acute or
chronic amebic dysentery are contractures
of the large intestine by adhesions and cica-
trices which sometimes cause obstruction
of the bowel, or more frequently marked
constipation due to the decrease in the cali-
ber of the bowel.

PHARMACOLOGY OF AMEBICIDES

At this time there is a need for a careful
appraisal of all available amebicides be-
cause of their extensive use by the armed
forces. Amebicidal drugs may be classified
as follows :

I. The Emetine Group

(a) Ipecac

(b) Emetine hydrochloride

(c) Emetine bismuth iodide

II. The Oxyquinoline Derivatives

(a) Chiniofon

(b) Vioform

(c) Iodoquin

(d) Diodoquin

III. The Organic Pentavalent Arseni-

cals

(a) Carbarsone

(b) Treparsol

(c) Acetarsone

IV. Miscellaneous Drugs

(a) Succinylsulfathiazole

(b) Bismuth compounds

The physician has at his disposal six po-
tent amebicidal agents : emetine, carbar-
sone, chiniofon, vioform, iodoquin and dio-
doquin. These six drugs will be discussed
and the less important drugs will be omitted
in this paper. Consideration of your time
and patience forbids detailed enumeration
of all drugs employed in the treatment of
amebiasis.

EMETINE

Emetine was first described by Pelletier,
the discoverer of quinine in cinchona bark.
Bardsley in 1829, was apparently the first
to use emetine in diarrheas and dysenteries,
and Rogers in 1912 obtained good effects
from the drug in amebic dysentery and
hepatitis.

Emetine is an alkaloid of ipecacaunha.
The hydrochloride salt is used because of
its greater solubility. For many years erne-

394

Arosemena — Treatment of Amebiasis

tine hydrochloride was regarded as a spe-
cific drug for amebiasis, but it is now
known that while it is most efficient in con-
trolling the symptoms of amebic dysentery,
it is not capable of eliminating amebic in-
fection when employed alone except in a
small proportion of cases. Craig1 has
pointed out that the disappearance of symp-
toms does not indicate elimination of the
infection in patients treated with emetine.
For this reason emetine hydrochloride
should not be employed in the treatment of
amebiasis to eliminate the infection but
only to control the symptoms of severe
diarrhea, after which one or the other of
the several amebicides can be used.

Emetine is a general protoplasmic poison
and exerts a cumulative toxic action since
it is excreted or detoxified slowly. The myo-
toxic action is particularly evident on heart
muscle in which it can cause a severe acute
degenerative myocarditis which may result
in sudden cardiac failure or death. Eme-
tine is the most toxic of drugs used in ame-
biasis. There is no known antidote for
emetine.

Nausea and vomiting may occur after
emetine. Severe diarrhea is not uncommon
and the stools may contain blood.

Emetine has a direct lethal action on
Endamoeba histolytica. The drug is more
effective against the motile forms than
against the cysts. Concentrations of eme-
tine necessary to kill cystic forms cannot be
safely obtained in man.

CHINIOFON

Chiniofon is an iodoxyquinoline deriva-
tive. It was introduced in 1921 under the
name of yatren. Anayodin is a propietary
preparation of chiniofon.

Chiniofon depends on iodine for its ame-
bicidal properties. It contains 26 to 28 per
cent iodine. The action of this drug is ap-
parently a direct one upon the motile forms;
as well as cyst forms. Its proper adminis-
tration is followed by elimination of the in-
fection in most cases. In therapeutic dos-
age it occasionally gives rise to severe diar-
rhea. Chiniofon is non-toxic in therapeutic
doses. Given intravenously the drug has
caused death, but there is no need or excuse

for using it by this route. This is one of
the safest drugs than can be used.

VIOFORM

Vioform is iodochlorhydroxyquinoline.
Vioform, like chiniofon, is directly amebi-
cidal due to its iodine content. Vioform
contains 37.5 to 41.5 per cent iodine and 11
per cent chlorine. The toxicity is greater
than that of chiniofon, but its toxicity is al-
most negligible. In large doses it produces
fatty infiltration of the liver in rabbits.

CAI! BAR SOX E

Carbarsone is an organic pentavalent ar-
senical. Carbarsone is directly amebicidal
by virtue of its arsenic content. This drug
contains 28.5 per cent arsenic and acts di-
rectly on the motile forms as well as cysts.
The toxic symptoms are those of arsenical
poisoning. Reed2 is of the opinion that car-
barsone is the best of all amebicidal drugs.
Craig11 (1934) places it second to chiniofon.
It is the most potent and least toxic ar-
senical amebicide, is as effective as any
other single agent, and rarely causes seri-
ous toxic effects.

DIODOQUIX

Diodoquin is a new oxyquinoline com-
pound. It contains approximately 64 per
cent iodine. The action of diodoquin upon
Endamoeba histolytica presumably is di-
rectly dependent upon the iodine content of
the drug. The dosage varies with the se-
verity of the infection. No toxic symptoms
have been reported save a heaache in rare
instances.

Forty-one cases were treated by Hum-
mel3 with diodoquin. This drug was found
to relieve the colonic and nervous symptoms
in a comparatively short time. Relapses
were not observed and toxic effects were
not encountered. Trophozoites and cysts
disappeared in all cases from 10 to 15 days
from the time treatment was begun. The
therapeutic effects on the colon and rectum
were observed by frequent sigmoidoscopic
and stool examination during and after
treatment. From his work he concludes
that this new oxyquinoline compound is a
valuable drug, fulfilling the criteria of the
ideal amebicide more than any other pre-
paration available at the present time.

Arosemena — Treatment of Amebiasis

395

The statement has been made that diodo-
quin is recovered quantitatively in the stool
and even with enormous dosage no absorp-
tion takes place. David,4 on the other hand,
found diodoquin to be occasionally lethal in
animals and capable of causing liver dam-
age and hence one can assume that absorp-
tion is possible after oral administration
under certain conditions. This was proved
by studying the blood iodine levels in
healthy human subjects given therapeutic
doses of either vioform or diodoquin. From
their results they found that a greater rise
in blood iodine occurred with vioform than
after diodoquin. More consistent absorp-
tion of vioform was noted. No symptoms
of iodine poison were observed. Diodoquin
is extremely insoluble in water, dilute acids
or alkalies. It is believed that toxicity of
an insoluble type of compound such as dio-
doquin may depend more on hyperacidity
or intestinal stasis than on the actual
amount of drug administered. When such
conditions are encountered the potential
danger of toxicity is greater with diodo-
quin, since it contains 63.9 per cent iodine
as compared with 41.5 per cent iodine in
vioform. Apparently the unreliability and
irregularity of the absorption of diodoquin
after oral administration is a major handi-
cap for its uncontrollable use. On the basis
of their results they believe that vioform
will prove a more reliable amebicide and
less likely, due to its less variable absorp-
tion, to cause toxic symptoms. The use of
either of these compounds in the prophy-
laxis of amebiasis must be rigidly controlled
and should not be carried out as extremely
as is done in the prophylaxis of malaria.
Any procedure intended to safeguard the
health of troops and workers in amoeba in-
fested areas is worth the risk of the occa-
sional case of toxicity to iodine which may
appear, however.

D’ Antoni0 has to date a total of 126
completely followed-up cases of amebiasis,
treated with diodoquin, a course of treat-
ment consisting of the administration of
three tablets of diodoquin (3.2 grains each)!
three times a day for 20 days. One hun-
dred and twenty-four of these patients were

cured, though in five cases a second course
of treatment was necessary. The minimum
criterion of cure is three negative stool
specimens secured at least two weeks after
the completion of treatment and preferably
spread over a week. Most of the cases in
this series, however, were examined by
much stricter criteria. The number of
stools examined averaged more than five
for each patient, and some patients were
under observation for periods ranging from
12 to 18 months.

Two of the patients in which diodoquin
failed were cured eventually by the use of
combinations of amebicidal drugs. Vari-
ous combinations were used with poor re-
sults. The plan was then conceived by ad-
ministering chiniofon long enough to pro-
duce six to 10 diarrheic stools (about two
days), for the mechanical cleansing effect
of the diarrhea, and of following this medi-
cation by the administration of diodoquin
in the usual dosage for five days. By this
combined treatment one patient was cured
in seven weeks, and since the conclusion of
treatment has had 12 negative examina-
tions, including two of material aspirated
at sigmoidoscopy. The other patient was
cured in eight weeks, and since has had 17
negative examinations including three of
aspirated material.

Only four of these patients treated with
diodoquin have exhibited mild toxic mani-
festations, chiefly headache and malaise, in
only one instance enough to require bed
rest for 24 hours. All of these patients had
rather severe amebic infections and it is
D’Antoni’s belief that the toxemia was not
caused by the drug but was due to the ab-
sorption of toxins from dead and disin-
tegrating Endamoebci histolytica.

SULFA STJXIDINE
(Succinylsidf athiazole)

Sulfasuxidine is one of the newer com-
pounds in the field of sulfonamides. Be-
cause observations on this drug have shown
that: (a) the flora of the gastrointestinal
tract is profoundly altered by it; (b) it
has definite bacteriostatic action in vivoj
(c) absorption from the gastrointestinal
tract is poor; (d) severe toxic reactions

396

Arosemena — Treatment of Amebiasis

have not been encountered; and (e) its
effect on bacillary dysentery is marked.
This drug has been used in the treatment
of amebic dysentery.

The mode of action is not clear. It is
doubtful that sulfasuxidine has any direct
action against ameba per se. It may, how-
ever, be that the drug acts to modify the
secondary bacterial flora, thereby aiding
in the healing of the ulcers and so support-
ing the host that it may be able to over-
come the amebic infection.

Knotts, et al.° presented six cases treated
with this drug and their results were highly
favorable. My main criticism on their
series of cases is that only six cases were
reported and their criteria of apparent cure
of these cases were hardly what most in-
vestigators consider adequate enough.

I shall not attempt to give their method
of treatment because at the present time
we have more efficient drugs. Until more
cases are reported on this drug and a
stricter criteria for apparent cure is estab-
lished, we are forced to consider this drug
simply as an experimental drug as far as
the treatment of intestinal amebiasis is con-
cerned.

MISCELLANEOUS

Mention must be made of the bismuth
salts, the nitrate and the less toxic subcar-
bonate which have a definite place in treat-
ment. These bismuth compounds act in a
purely mechanical manner as protectives
and demulcents to the mucous membrane
of the colon. They are indicated in all
cases where amebic ulcers are slow to heal
and where, as frequently is the case,
secondary pyogenic infection has taken
place.

CONTRAINDICATIONS TO COMMON AMEBICIDES

Emetine: Emetine should not be used if

organic disease of the heart or kidneys is
present. It is also contraindicated in chil-
dren unless there is severe dysentery which
has failed to respond to other measures.
Emetine is best not used during pregnancy.

Chiniofon : Chiniofon should not be used
in the presence of iodine intolerance and
must be given with caution to patients with
thyroid disease. Liver damage is also a

contraindication. In those individuals in
whom a persistent and severe diarrhea oc-
curs from the drug, chiniofon should not
be given.

Vioform : The contraindications for

vioform are the same as for chiniofon.

Diodoquin : The contraindications for

diodoquin are the same as for chiniofon and
vioform.

Carbarsone : Carbarsone is contraindi-

cated if renal or hepatic disease is present.
The patient’s vision and skin especially
must be carefully observed for manifesta-
tion of arsenical poisoning.

THERAPY OF AMEBIASIS

The modern therapy of amebiasis in-
cludes much more than the treatment of
that stage of the infection known as amebic
dysentery, although in most works upon the
subject treatment is practically confined
to the treatment of acute and chronic ame-
bic dysentery. The treatment of amebiasis
includes the treatment of carriers, those
having mild symptoms of infection, those
presenting definite attacks of diarrhea,
those developing acute and chronic amebic
dysentery, as well as those having abscess
of liver, lung and other organs or tissue.

The treatment of carriers is of tremen-
dous importance at all times in the control
of the disease and more so now that the
American soldiers a)re returning from
heavily infested areas from all over the
world. In this infection we have the ap-
parent paradox that the patient, when suf-
fering from active symptoms, is relatively
harmless so far as transmitting the infec-
tion is concerned, but becomes a danger
when he has recovered from the infection.
Cysts are the only form which is infectious
because the motile forms are destroyed by
gastric hydrochloric acid if ingested. The
carrier remains a potential source of in-
fection to himself and to others and is an
extremely serious public health problem,
especially if he handles food. Amebic ab-
scesses of the liver, brain and lung may de-
velop in carriers who have had little or no
previous symptoms of intestinal amebiasis.

The criteria as to whether amebic infec-
tion of the intestinal tract has been cured

Arosemena — Treatment of Amebiasis

397

depends on laboratory and not medical ex-
amination. Disappearance of symptoms
does not mean cure of amebiasis. Evidence
of cure is acceptable if it consists of nega-
tive stool examination at weekly intervals
for four weeks after completion of treat-
ment, and at monthly intervals thereafter
for five months. Repeated courses of medi-
cation are sometimes required to effect a
cure. Treatment should be resumed when-
ever the stool again becomes positive for
amoeba.

Amebiasis occurs throughout the United
States, and the medical profession should
abandon the idea generally held at the
present time that amebiasis is a tropical
disease.

The most important aspect of treatment
is actually the control of this disease. The
prophylaxis of amebiasis is that of any
disease transmitted by contaminated food
and drink. As mentioned previously the
detection and treatment of carriers is the
most important prophylactic measure. By
and large, especially in places otherwise
well sanitated, the food handler who is a
carrier is the most significant factor in the
transmission of the disease.

TREATMENT OF CARRIERS

In carriers a drug should be used which
will not interfere with the individual’s
work and which can be taken without dis-
comfort or injury to health. These re-
quirements are fulfilled by several of the
amebicides, namely: carbarsone, chiniofon,
vioform or diodoquin. Chiniofon is usually
the drug of choice, but diodoquin will prob-
ably take its place in the years to come.
Chiniofon, three to four pills (4 grains
each) three times a day for eight to 10 days
may be given. The full dose sometimes has
the disadvantage of causing severe diar-
rhea. It is not a toxic drug and may be used
safely in mass treatment; the treatment
does not interfere with the occupation of
the patient unless it gives rise to severe
diarrhea. A single course of treatment is
usually curative in asymptomatic carriers,
but the course may be repeated, if neces-
sary, after an interval of two weeks has
elapsed. No precautions are necessary as

regards exercise or diet. If cysts are not
eliminated with two courses, diodoquin,
carbarsone or vioform can be tried.

Diodoquin, three to four tablets (3.2
grains each) three times a day for 20 days
is given, but larger doses may be tried. Car-
barsone, one capsule (4 grains each may
be given twice a day for 10 days and re-
peated in 10 days if necessary. Vioform
is administered in the form of one capsule
(4 grains) three times a day for 10 days and
repeated in 10 days if necessary. In very
resistant cases a combination of chiniofon
and diodoquin has been very efficient in
D’Antoni’s6 series of cases. Chiniofon is
given for two to four days, enough to pro-
duce six to 10 diarrheic stools, and then
diodoquin in customary dosage is given for
five days.

ACUTE DYSENTERY

Bed rest for patients with diarrhea is es-
sential. Acute symptoms can be controlled
with 1 grain of emetine hydrochloride given
subcutaneously once a day until symptoms
have subsided (which is usually four to six
days) but not to exceed 12 grains. Diodo-
quin, chiniofon, carbarsone or vioform can
be given once the acute symptoms have sub-
sided. Emetine finds its most useful thera-
peutic field in the control of the acute dy-
senteric symptoms. Chiniofon, carbarsone
and vioform can be used in the same dos-
age as mentioned for carriers. Diodoquin
can be given in larger doses with better re-
sults— 10 to 12 tablets, three times a day
for 20 days.

While the patient is being treated with
emetine, a careful watch should be kept for
symptoms of intolerance, as this drug is
sometimes toxic even in therapeutic dos-
age. The symptoms of emetine poisoning
are severe diarrhea, neuritis, myocarditis,
great muscular weakness and nervous pros-
tration ; if any of these symptoms appear
the drug should be discontinued.

Emetine-bismuth iodide may be substi-
tuted for emetine hydrochloride ; it has the
advantage of oral administration, and is
thought by some to be more efficient. This
drug is supplied in enteric coated pills (3
grains). Not more than 3 grains should be

398

Arosemena — Treatment of Amebiasis

administered per day, preferably at night,
for twelve consecutive days. After com-
pletion of the treatment, the stools should
be examined and if cysts or trophozoites are
still present, chiniofon or any other of the
amebicides should be administered as al-
ready recommended.

In D’Antoni’s6 experience, retention
enemas of amebicidal drugs have never been
necessary and he seriously doubts their ra-
tionale. “The introduction of amebicidal
solutions, at most 200 c.c., into the lower
bowel can scarcely be expected to correct
an infection involving the colon, some-
times in its entirety.” In view of the effi-
cacy of present day amebicides, the indica-
tions for treatment by retention enemas
seem very limited.

In the treatment of the dysenteric stage
of amebiasis with any of the drugs men-
tioned the patient should remain in bed un-
til the completion of the treatment in order
to receive the best results.

CHRONIC AMEBIC DYSENTERY

The chronic form of amebic dysentery
may follow severe acute attacks or may be
chronic in type from the beginning, there
being a history of repeated attacks of diar-
rhea in which small amounts of blood and
mucous occurred in the stool.

If patients are seen during acute exacer-
bations with severe dysentery, the treat-
ment should be that already described for
acute amebic dysentery, while if the pa-
tient is seen during intervals between
dysenteric attacks, a course of diodoquin or
another of the previously mentioned amebi-
cides is indicated.

In patients who have suffered from many
relapses of acute amebic dysentery, the
prospects of cure with any method of treat-
ment are poor. Even if a cure of the in-
fection is secured, the patient may con-
tinue to have attacks of diarrhea if ex-
treme ulceration has occurred in the intes-
tine resulting in the replacement of large
areas of mucous membrane with scar tis-
sue through which absorption of fluids is
impossible.

Ghosh7 suggests that in treating cases of
chronic amebiasis attention should be paid

to the adjustment of the diet in such a way
as to keep the reaction of the stool alkaline.
Carbodydrates tend to make the stool highly
acid. Alkali by mouth has little influence
on the reaction of stools. Increased protein
diet and decreased carbodydrate invariably
render the stool alkaline. Ghosh states that
positive deductions can not be drawn from
his three cases but that it is fairly possible
that this point might help in cases which
persistently do not improve with what
seems to be adequate treatment.

The general treatment of amebiasis in
those suffering from diarrheal or dysen-
teric attacks consists in bed rest and atten-
tion to the diet and general physical welfare
of the patient. If dysenteric symptoms are
very acute, it is best to withhold all foods
for two or three days, and if food is given
it should consist of barley water, albumin,
milk with lime water and thin broths.
When the acute symptoms subside, poached
or soft boiled eggs, soft puddings and thick
gruels may be given and as the patient im-
proves a light soft diet may be substituted.
Extreme care is necessary to avoid foods
that are known to irritate the intestine.
Alcohol should be forbidden to all individ-
uals who have symptomatic amebiasis, and
even in carriers excessive indulgence in al-
cohol often results in appearance of the
symptoms of diarrhea or of dysentery.

AMEBIC HEPATITIS

The treatment of amebic hepatic infec-
tion is entirely surgical, although it should
be realized that this may consist of either
conservative or radical measures. Early
recognition of amebic hepatitis and the in-
stitution of conservative measures during
this presuppurative stage may prevent pro-
gression to actual abscess formation. Even
in cases in which early abscess formation
has occurred, conservative measures are
frequently sufficient to effect complete
resolution.

The term conservative therapy is used to
signify the administration of the specific
drug emetine hydrochloride, with or with-
out aspiration, depending upon the presence
of indications for the latter. In early cases

Arosemena — Treatment of Amebiasis

399

of amebic hepatitis, utilization of emetine
alone may be sufficient. In other cases,
however, a true abscess has apparently de-
veloped which requires, in addition to the
emetine, evacuation of its content by as-
piration.

At present, it is the concensus of most
authorities that emetine hydrochloride is
the most valuable drug in amebic hepatic
involvement, and even large abscesses may
completely disappear under emetine therapy
alone. Every case of suspected amebic he-
patitis or amebic abscess should be given
the advantage of a course of emetine before
any procedure is used, unless rupture of the
abscess appears imminent. In many cases,
especially in those with early small ab-
scesses, no other therapy will be required.
However, in the majority of cases in
Ochsner’s8 series, evacuation of the abscess
contents was necessary.

The evacuation of amebic abscess reigns
totally in the realm of surgery and the
technics used are beyond the scope of this
paper.

The drug is preferably administered sub-
cutaneously, as emetine hydrochloride in
daily doses of 1 grain until 10 grains have
been given. Because of its toxicity in ex-
cessive dosages and its cumulative action,
the noxious effects of this drug should be
realized and considerable care exercised in
its use.

Immediately after completion of therapy
of the amebic hepatic condition the patient
should be given a course of therapy for the
intestinal amebiasis. Even though the lat-
ter cannot be demonstrated clinically, it
should be assumed to exist once the diag-
nosis of either amebic hepatitis and hepatic
abscess has been established.

CONCLUSIONS

1. Emetine has no rival in the treatment
of the acute symptoms of intestinal ame-
biasis and in amebic hepatitis, and even
presuppurative amebic abscess.

2. On the basis of D’Antoni’s 126 cases
treated with diodoquin it is found that this
new drug is essentially non-toxic in thera-
peutic doses, and is 92 per cent effective in
single courses and 99 per cent effective if

two or more courses .are used in the treat-
ment of intestional amebiasis. No drug pre-
viously used in the treatment of amebiasis
has given such consistently satisfactory re-
sults. A word of caution, however, is ne-
cessary. This is a small series and one will
have to observe more cases before the true
evaluation of efficacy can be established.
Diodoquin is apparently the most effective
drug presently available for the treatment
of amebiasis.

The claims for most of the amebicidal
drugs were evaluated before the zinc sul-
fate technic for cysts and ova came into
use. Evaluation of the amebicides using
this technic as a criteria for cure should
be done before a true knowledge of the ef-
ficacy of each drug can be accurately eval-
uated.

3. In the treatment of chronic and sup-
purative hepatic abscess, emetine plus sur-
gical aspiration is the method of choice.

4. Other extra intestinal complications
of amebiasis, such as lung abscess, are to-
tally surgical procedures beyond the scope
of this paper.

REFERENCES

1. Craig, C. F. : Amebiasis, a general review, Internat.
Med. Digest, 24 -.54, 1034.

2. Reed, A. C.. Anderson, H. H., David. N. A., and
Leake, C. D. : Carbarsone in treatment of amebiasis., .1.
A. M. A„ 98 :189, 1932.

3. Hummel, II. G. : Results of treatment of amebiasis
with diodoquin. Am. .T. Digest. Dis., 6 :27, 1939.

4. David, N. A.. Phatak, N. M., and Zener, F. B. :
Iodochlorohydroxyquinoline and diodohydroxyquinaline.
Animal toxicity and absorption in man, Am. J. Trop. Med.,
24:29. 1944.

5. D'Antonj, .7. S. : Diodoquin therapy in amebiasis.
Unpublished.

6. Knotts. F. L ., and Thompson, J. I... Jr. : The use of
sulfanoxidine in the treatment of amebiasis, Med. Ann.
District of Columbia. 11 :375. 1942.

7. Ghosh, II. : A probable cause of the difficulty of
treating chronic amebic infections in this country, Indian
M. Gaz., 74 :27, 1939.

8. Ochsner, A., and DeBakey, M. : Amebic hepatitis and
amebic hepatic abscess, Surgery, 13 :612, 1943.

9. Ochsner, A., DeBakey, M., Klein sasser, R., and
DeBakey, E. :Amebic hepatitis and hepatic abscess, Rev.
Gastroenterology, 9 :438, 1942.

10. Davis, F. : Amebiasis — diagnosis and treatment,
Mississippi Doctor, 20 :lo4, 1942.

11. Chopra, R. N.. and Chopra, I. C. : Treatment of
chronic intestinal amebiasis, Indian Med. Gaz.. 77 :65,
1942.

12. Craig, C. F. : The diagnosis and treatment of in-
testinal amebiasis. South. Med. J., 25 :1207. 1937.

13. Goodman. L., and Gilman, A. : Drugs LTsed in the
Chemotherapy of Amebiasis. The Pharmacological Basis
of Therapeutics. 4th Ed. The McMillan Co.. New Vo k,
1942. Tp. 931-941.

400

Wright — Vitamins and Intestinal Function

14. Faust. E. C. : The chemotherapy of intestinal para-
sites, J. A. M. A., 117 :1331, 1941.

15. Muk lens, P. : Diagnosis and treatment of amebic
dysentery, Deutsche med. Wchnschrift, 60 :017, 1940.

1G. Moser, R. H. : Amebiasis and amebic dysentery, J.
Indiana State Med. Assn. 32 :301. 1939.

17. Ugranker, S. S. : Treatment of dysenteries, Medical
Digest, 6 :424, 193S.

18. Rogers, W. D. : Amebiasis, J. Florida Med. Assn.,
24 :333, 1937.

O

THE EFFECT OF VITAMINS ON THE
INTESTINAL FUNCTION

L. D. WRIGHT, JR., M.D.

New Orleans

INTRODUCTION

It was some time ago, when I was a pre-
medical student, that I first became inter-
ested in vitamins. There were several
reasons for this interest: (1) the usual in-
terest shown by the laity and the profes-
sional groups over these new “energy
pills”; (2) the fact that my family was
more than the average “vitamin addict” ;
and (3) the observation of what seemed to
be a “miracle” of treatment. This observa-
tion, viewed in the present light of knowl-
edge concerning the function of vitamin B1
could, I believe, truly be termed a miracle.
The miracle had to do with a man, aged
33, diagnosed by the local physician as a
case of low intestinal obstruction. The con-
dition had existed for five days, and had
been verified by a surgical consultant. For
some unknown reason, the local physician
decided to give the man a massive dose of
vitamin B,, intravenously, the day before
the operation was scheduled. The condi-
tion cleared up in a matter of hours, and
the patient was back on his feet and feel-
ing fine in a week. The patient has re-
mained well and in good health since.
Whether this effect was due to B,, whether
the true diagnosis was missed, or whether
something unforeseen and unrecognized
happened is purely a matter of conjecture.
Of course, you the reader, like me, will be
tempted to say that the “cure” was cer-
tainly not due to the Bj administration; but,
in reality, who can say definitely yet.

Nevertheless, no matter what the effect
of the vitamin B, on this patient, it did
have the effect of stimulating interest on

my part in the effect of vitamins on the
intestinal function.

The present trend of study in this field
has turned, more or less as a matter of ne-
cessity, to a study of the intestine in the
various deficiency states and the effects of
vitamin administration in these conditions.
With the few exceptions that will be noted
later, the administration of vitamins to the •
normal person has very little or no effect;
and hence a study along this line would be
much less fruitful than the above.

Vitamin deficiency states may be of two
types: (1) primary, and (2) secondary. A
'primary deficiency is one which occurs
without obvious cause. It is one in which,
however, a consistently deficient diet may
be a factor, such as in sprue or pellagra.
A secondary deficiency is one which is
caused by, or is associated with, a recog-
nizable disease of the alimentary tract. It
is seen, however, that the manifestations
of the deficiency per se would be the same
in each ; although they may be partially or
completely masked in the secondary type.

A state of vitamin deficiency, either clin-
ical or pre-clinical, may develop due to
inadequate intake. On the other hand the
intake may be adequate but for various
reasons, physiologic or pathologic, there
may be increased need, decreased absorp-
tion, increased destruction, or decreased
utilization of the vitamins. These factors
may be present singly or in various combi-
nations.

In a study of the small intestine in defi-
ciency states, abnormalities may be recog-
nizable incidentally during the usual gas-
trointestinal series and fluoroscopy. The
best method for its study possibly, is re-
peated roentgen examinations at 30 minute
intervals after the ingestion by the patient
of a barium sulfate suspension on a fast-
ing stomach. The films are usually devel-
oped and inspected at once, and at this time
any needed modifications to the procedure
may be made. Fluoroscopic examinations
are also made during the study. If the
BaS04 has entered the cecum, food is usu-
ally given at five hours, and the study is
completed.

Wright — Vitamins and Intestinal Function

401

Obviously the abnormalities of the small
intestine associated with vitamin deficien-
cies vary with the severity and duration of
the disorder. Upon institution of therapy,
the improvement in intestinal function
usually lags behind the clinical improve-
ment of the patient.

There are no special examinations for
observation of the large intestine during
deficiency states, although the barium en-
ema, gastrointestinal series, proctoscopy,
and stool examination are helpful proce-
dures.

The various vitamins will be taken up for
study in alphabetic order.

VITAMIN A

Vitamin A is fat soluble. It is an un-
saturated alcohol derived from the reddish
yellow pigment carotene. When taken in
the food, about 20 per cent of this carotene
is converted into vitamin A in the liver
where it is also stored. Bile is necessary
for the absorption of carotene, which is ab-
sorbed much less readily than vitamin A.
Absorption of both, however, is favored by
the presence of fat in the intestine.

Vitamin A is essential for the mainte-
nance of the normal function and integrity
of the epithelial tissues of the animal or-
ganism. As a result of deficiency of this
essential substance there is atrophy of the
epithelium concerned, conversion into a
stratified squamous variety, and suppres-
sion of the normal secretions. As a result
of these changes, the susceptibility of the
tissues to intercurrent secondary infection
is increased ; for it is a well known fact that
healthy mucous membranes with their pro-
tective secretions are the “first line of de-
fense” against infection. However, the de-
ficiency of just about any essential nutri-
tional requirement will lower resistance to
infection ; and the physician is highly specu-
lative who sees any beneficial results from
vitamin A therapy during an acute infec-
tion or as a prophylactic measure, unless
such a specific deficiency is present. Stry-
ker and Janota1 have made observations on
the permeability of the intestinal wall in
rats deficient in 'vitamin A and in control
animals, using S. enteritidis and toxin of Cl.

botulinum as test substances. No note-
worthy differences between the two groups
of rats were demonstrated. This work has
been confirmed by others.

Hyperkeratosis with ulceration of the
forestomach of rats as a result of vitamin
A deficiency has been repeatedly reported.
However, most authorities are of the opin-
ion that this cannot at all be regarded as a
specific lesion.

The most likely pathologic changes in the
gastrointestinal tract in vitamin A defic-
iency are alterations in the teeth, inflam-
matory or atrophic changes in the oral,
stomach and intestinal mucosa and inflam-
matory or cystic changes of the accessory
glandular organs. These changes may in-
terfere with absorption from the intestine
and may lead to hypochlorhydria or achlor-
hydria. Symptomatically the most com-
mon complaint, and the only gastrointesti-
nal symptom which has been noted with any
frequency, is diarrhea. The cause for this
diarrhea is not clear, although it seems most
likely to be related to atrophic or inflam-
matory changes in the mucosa of the large
or small intestine or perhaps to the achlor-
hydria. However, at autopsy, the gastroin-
testinal tract is usually comparatively nor-
mal. This paucity of gastrointestinal symp-
toms and pathologic changes in man is sur-
prising when one recalls that a large part
of the gastrointestinal tract is made up of
epithelial tissue.

Daily requirements of vitamin A are 3000
units for the normal adult, 6000-8000 units
for the growing child, and 5000 units for
the pregnant or nursing woman. The re-
quirements are, of course, increased in a
specific deficiency state in proportion to the
severity of the condition. The experimen-
tal basis for the use of vitamin A in gas-
trointestinal disorders is not yet clearly es-
tablished.

Hemorrhagic diarrhea may be part of a
toxic syndrome caused by over dosage.

VITAMIN B (THE “B” COMPLEX)

This group of vitamins which are group-
ed under the heading of vitamin B are
water soluble and are stored very poorly in
the human body.

402

Wright — Vitamins and Intestinal Function

The following findings have been noted
in numerous cases studied extensively by
various authorities in which some defic-
iency condition appeared to play either a
major or minor part. The patients were
diagnosed as having a vitamin B deficiency
because of their response to specific ther-
apy :

A. Motility

1. Hypermotility: In the earlier, less ad-
vanced stages rapid passage of the barium
sulfate was repeatedly noted.

2. Hypertonicity: This finding like the
above was noted in the earlier, less ad-
vanced stages. It was often evidenced by
a reduction in the size of the lumen to one-
half or even one-quarter of its normal size.

3. Hypomotility : In the later stages of
the deficiency state, slow passage of barium
sulfate was noted. This, with the hypoton-
icity often results in dilatation of the colon
with degeneration of the mucous mem-
brane.

4. Hypotonicity : This also was noted in
the later stages of the deficiency state, and
was evidenced by a dilatation of the bowel.

5. Abnormal segmentation : Areas of

spasm of variable length interspersed with
areas filled with barium sulfate served to
give the picture of numerous discrete mass-
es of barium. In advanced stages, such as
in non-tropical sprue, for example, these
filled segments are usually associated with
hypomotility. In the earlier stages, the
masses of barium sulfate are shorter and
may be the width of the normal lumen or
even narrower; this is called hypertonic
segmentation.

On fluoroscopic examination little for-
ward progression of the opaque media is
seen ; however, there is an almost continu-
ous activity, with jumping of the areas of
contraction back and forth. Pressure on a
distended segment often results in an im-
mediate contraction and a shifting of the
opaque material.

6. Scattering effect : In some cases, as
the main mass of barium sulfate passes on,
small irregular masses linger behind and
give small shadows of irregular size and

shape. This effect seems to be due in part
to a disturbance in the function of the cir-
cular muscle and in part to a disturbance
in the movement of the mucosa which de-
pends on the muscularis musoca.

7. Gas and fluid levels: In the advanced
cases this finding may be marked, and flat
plates of the abdomen may suggest the pos-
sibility of ileus. The presence of gas in
considerable amounts is thought to be a
manifestation of a disturbance in the abil-
ity of the mucosa to absorb gas.

Whether these findings are due to a
primary defect of the intrinsic nervous
mechanism, or to a secondary one, due per-
haps to a vitamin B deficiency, has not yet
been completely settled ; but there are very
strong arguments in favor of the latter.

B. Mucous Membrane

1. Reduction to complete obliteration of
the mucosal folds may be seen, depending
upon the stage of the condition.

2. Exaggeration of the mucosal folds, on
the other hand, may be seen. The cause of
these conflicting findings is not well under-
stood.

C. Gastric Retention

This is frequently found in well marked
primary deficiency states ; and a good sized
six hour residue of barium sulfate may be
present, with sluggish, ineffective peristal-
sis and often with antral spasm.

D. Disturbance in Carbohydrate and Fat
Digestion and Absorption

In the hypomotile type of chronic enter-
itis, evidence of impaired fat digestion and
absorption is found, just as it is in the
hypermotile type. This finding may be ex-
plained in the hypermotile type by the rapid
passage through the small bowel; but ob-
viously this could not be the explanation in
the hypomotile type.

Free and Leonards2 3 have shown that, in
rats deficient in vitamin B, the intestinal
absorption of galactose was 35 per cent
less than in normal rats. Later work show-
ed the rate of intestinal absorption of galac-
tose to be impaired 66 per cent by thiamin
deficiency, 12 per cent by pyridoxin de-
ficiency, 15 per cent by pantothenic acid
deficiency, and unaffected by riboflavin.

Wright — Vitamins and Intestinal Function

403

E. Miscellaneous

1. Dalldorf, Gilbert and Kellogg5 showed
that gastric ulcers appeared in a large per-
centage of rats fed a B, deficient diet, and
therefore suggested that B1 therapy should
be instituted in the treatment of gastric
ulcers in humans. This work has been con-
firmed by others. However, most author-
ities are of the opinion that the ulcers arise
secondarily in the course of the vitamin B,
deficiency, probably as part of the response
of the stomach to a generalized systemic
deficiency condition.

2. It has been found that “folic acid”
*and biotin promote the synthesis by resi-
dual intestinal bacteria0 of additional es-
sential dietary factors. Thus these sub-
stances may prove to be a valuable adjunct
to sulfonamide therapy, as this drug af-
fects primarily the vitamin synthesizers
(colon bacilli) and leaves more or less un-
influenced the vitamin requirers (lacto-
bacilli, streptococci, and anaerobic bacilli).
Para-amino-benzoic acid partially counter-
acts the effect of the sulfonamides, espec-
ially the chief offender, sulfasuxidine, on
vitamin synthesis in the intestinal tract.

A large number of gastrointestinal symp-
toms, including anorexia, constipation,
diarrhea, dysphagia, flatulence, and vomit-
ing, have been ascribed to deficiency of
components of the B complex. Of these
symptoms it is clearly established that anor-
exia and diarrhea accompany vitamin Bx
deficiency in man.

It is quite clear that thiamin and nicotinic
acid are essential for normal functioning of
the gastrointestinal tract. It is difficult to
establish a definite part of the B complex as
the specific agent in the etiology of the va-
rious and sundry changes in the gastroin-
testinal tract. It is much easier to ascribe
the changes to the group as a whole. It is
undoubted though, in an over all view, that
B, is by far the most important member of

*The term “folic acid” refers to concentrates
which furnish . an essential growth factor for L.
casei. Although the activity of such a concentrate
is ascribed to the “fqlic acid” content, other sub-
stances are present, and in reality only a small
amount of folic acid.

the group, with nicotinic acid as very close
second.

Cheney7 treated three groups of patients
with vitamin Bx with the following results :

1. Chronic diarrhea: Seven patients

with chronic diarrhea of unknown etiology
were treated with thiamin and three of
them also received liver extract. Five of
them were asymptomatic except for their
diarrhea. All seven patients responded to
the therapy.

2. Mucous colitis : This group was com-
prised of six patients, all of whom received
vitamin B^ and all but one of them received
liver extract during their course of treat-
ment; all improved with treatment.

3. Idiopathic ulcerative colitis: There

were 11 cases in this group, and all but one
was definitely improved while taking in-
jections of liver extract with vitamin Bx.

Chesley, Dunbar, and Crandall treated 44
patients with the so-called functional gas-
trointestinal disturbances. Such disturb-
ances perhaps constitute the majority of all
digestive conditions for which the physician
is consulted, and are ascribed by a great
many authorities to vitamin deficiencies.
Their results with vitamin B complex and
nicotinic acid are as follows8 :

Per cent

Per cent

satisfactory

satisfactory

in vitamin

in nicotinic

B complex

acid

Flatulence

67

57

Abdominal distress

64

56

Alternating constipation
and diarrhea

74

69

Constipation only

75

71

Diarrhea only

50

50

Weakness and fatigue

60

17

Nervousness

63

16

Anorexia

100

30

Williams, Mason, Wilder, and Smith con-
ducted a study to determine what happens
when the diet is markedly deficient in
thiamin. Extreme anorexia, nausea, vomit-
ing, and constipation were prominent in
the train of symptoms. The earliest effect
of vitamin Bt deficiency is loss of appetite.
This occurs some time before the appear-
ance of polyneuritis; it is undoubtedly due
in part at least, to the atony of the gastroin-

404

Wright — Vitamins and Intestinal Function

testinal tract. Thiamin is undoubtedly the
one vitamin most likely to be deficient in
the average American diet. This is a good
theoretical explanation for the etiology of
the large number of people who are so
“finicky” about their food.

The daily requirement of thiamin in the
normal individual is 1.5 to 2.3 mg. as es-
tablished by the Food and Nutrition Board
of the National Research Council. This re-
quirement is, however, influenced by sev-
eral factors, such as the basal metabolism,
the quality and the quantity of the diet, pe-
riods of active growth, pregnancy, and lac-
tation. It is increased by a diet high in
carbohydrate but decreased by one high in
fat.

Vitamin B., at first designated as a part
of the B complex, has since been shown to
be itself a complex — in the B complex. It
contains several factors, the most import-
ant of which are riboflavin, nicotinic acid,
pyridoxin, and pantothenic acid. There are
various other members of the group which
at the present time are thought to be unim-
portant.

Riboflavin, per se, has little or no demon-
strable effect on the gastrointestinal tract.
Its daily requirements are 2. 2-3. 3 mg.

Nicotinic acid (niacin) is the well known
P-P (pellagra preventing) factor in the B
complex. One of the most outstanding fea-
tures of pellagra, the result of a pronounced
deficiency of this factor, is anorexia, diges-
tive disturbances, and diarrhea, which may
occasionally prove intractible. There is
sometimes constipation. In every case of
pellagra in which nicotinic acid has failed
to relieve the diarrhea, there is some or-
ganic lesion to account for this failure us-
ually. The daily requirements for a nor-
mal individual are 15-20 mg. In pellagra
the dosage varies with the physician, but a
good program is as follows: 1,000 mg. in-
travenously on the first day, and 500 mg.
intravenously daily for a week, followed by
repeated smaller oral doses. This dosage is
extremely variable, however.

Pyridoxin (vitamin B,;) has little known
effect on the digestive tract. Some work
has been done recently concerning the use

of this factor in the treatment of “morning
sickness.” The daily requirement for the
normal person is about 2 mg.

Pantothenic acid is also still rather ob-
scure as concerns its effects. Intussuscep-
tion has been observed in rats with panto-
thenic acid deficiency, the significance of
which remains unknown. The daily re-
quirement for the normal individual is
about 5 mg.

VITAMIN C (ASCORBIC ACID; ANTI SCORBUTIC;

CEVITAMIC ACID)

Vitamin C is water soluble. Its essential
function is to maintain the integrity of the
intercellular ground substance in which tis-
sue cells are distributed. In scurvy, the ef-
fect of vitamin C deficiency, there is, as in-
dicated above, a reduction of the intercellu-
lar cement substance, resulting in a weaken-
ing of the endothelial wall of the capil-
laries. The outstanding gastrointestinal
symptoms in scurvy are related to gingivi-
tis. Anorexia and diarrhea may be present.
Study of human material does not support
the new theory that the gastrointestinal
tract suffers in a conspicuous fashion from
vitamin C deficiency; however, minute
hemorrhages and occasionally larger ones
with secondary necrosis and ulceration are
found.

A great deal of controversy has sur-
rounded the possible role of vitamin C de-
ficiency in cases of peptic ulcer, other ul-
cerative lesions of the gastrointestinal tract,
and in bleeding from ulcers and other
lesions. The urinary excretion of vitamin
C is large in patients with ulcers, and the
capillary fragility test will often show that
vitamin C has failed to be absorbed and
stored, but this may be due to a decreased
intake or absorption, or increased destruc-
tion. The relation of hemorrhage from the
gastrointestinal tract due to vitamin C de-
ficiency remains unsettled. It would seem
that since vitamin C certainly is not harm-
ful and might possibly be helpful, that it
should be an addition to the diet of patients
with gastric ulcer.

There have been numerous clinical re-
ports, especially from European workers,
that vitamin C occasionally gives rise to in-

Wright — Vitamins and Intestinal Function

405

testinal colic and to an increase in intestinal
motility. Haag- and Taliaferro9 have ob-
served the effect of ascorbic acid on the
isolated guinea pig colon. They found that
ascorbic acid in concentrations ranging
from 1-10 mg. per cent caused a great in-
crease in tone in from one to two minutes
after application. Thereafter the tone
gradually decreased until it reached normal.

The daily requirement of vitamin C for
the normal adult is 75-100 mg., but this
varies considerably, being increased in in-
fections and other conditions which tend to
deplete the vitamin stores. Such an intake
is absolutely indicated in all cases of gas-
trointestinal ulceration. In acute deficien-
cies one may give as high as 1000 mg. for a
few days and then 100-300 mg. daily until
the deficiency state is under control.

A substance similar to vitamin C and
having practically the same effects has been
reported by Russnyak and Szent-Gyorgyi
and termed “citrin.” Its existence is now-
disputed by C. S. King and others.

VITAMIN D

This is a fat soluble vitamin, a deficiency
of which causes rickets in the child.

In animals there is very little, if any,
evidence that deficiency of vitamin D leads
to impairment of gastrointestinal function
or structure. Atony of the intestine has
been described as an accompaniment of
rickets, but the relation of it to deficiency
of vitamin D is not clear.

In childhood, when there is defective ab-
sorption of fat and calcium, a fatty diar-
rhea may develop as part of the syndrome
characterized celiac rickets. The absorp-
tion of vitamin D is apparently defective in
this condition; and it responds to the ad-
ministration of the vitamin, as does a simi-
lar condition in adults called idiopathic
steatorrhea or non-tropical sprue.

Daily requirements of vitamin D are 400-
800 units daily, and possibly a little more
during pregnancy and lactation. Experi-
ments are under way using massive par-
enteral doses of vitamin D.

Some adults whb are treated with large
doses of vitamin D, for some reason may

develop intense diarrhea along with other
symptoms of overdosage.

VITAMIN E (ANTI-STERILITY)

This vitamin E is a fat soluble vitamin.
Evidence is lacking that a deficiency results
in significant gastrointestinal abnormality.

VITAMIN K (ANTI-HEMORRHAGIC)

This is a fat soluble vitamin. Bile is nec-
essary for its absorption, and fat interferes
with its absorption.

Evidence is not complete enough to sug-
gest that deficiency of vitamin K may re-
sult in any abnormality of gastrointestinal
function or structures other than those
changes associated with bleeding. Briefly,
it is of value in the treatment of the hemor-
rhagic diseases caused by a deficiency of
prothrombin, such as hemorrhagic disease
of the newborn and hemorrhagic diseases
associated with certain diseases of the gas-
trointestinal and bilary tracts. Dosage is
estimated and determined by a study of the
prothrombin level. Toxic vomiting and
diarrhea may result from overdosage.

SUMMARY

In the above discussion, a number of im-
portant actions of the various vitamins on
the intestine and the intestinal function
have been described and discussed. While
some of these effects are clearly establish-
ed, others are not; and, as a consequence,
many of the findings enumerated are not
universally agreed upon. An attempt was
made to stress the established findings and
indicate the others. This was done by
means of the presentation of both labora-
tory and clinical data.

In the diagnosis of vitamin deficiency
states such as have been studied, it is
curious that evidence of deficiency of most
of the vitamins is to be found in the mouth.
This fact should be another stimulus to the
modern practitioner to return somewhat to
the time-taking physical diagnostic meth-
ods of his predecessors rather than rely too
much upon the mechanical contrivances
now at his disposal.

The physician should also remember that
vitamin deficiencies are usually multiple,
and hence not expect to find the typical pic-

406

K N I G H T — Fil a via s is

lure of a single vitamin deficiency. He
should remember this when he thinks of
treatment; but first of all he should never
forget that there is no completely satisfac-
tory substitute for an adequate diet.

REFERENCES

1. Stryker. W. A. and .lanota. M. : Vitamin A deficiency
and intestinal permeability to bacteria and toxin, J. Infect.
Die., 69 :243. 1941.

2. Free, A. H., and Leonards. .T. R. : The effect of vita-
min B deficiency on the intestinal absorption of galactose
in the rat, J. Nutrition, 24 : 495. 1942.

3. Leonards, J. R.. and Free, A. H. : The effect of
thiamin, riboflavin or pyridox'ine deficiency on the intes-
tinal absorption of galactose in the rat, .1. Nutrition, 20:
499, 1943.

4. Leonards, ,T. R., and Free, A. H. : The effect of panto-
thenic acid on the rate of intestinal absorption of galac-
tose in the rat, J. Nutrition. 25 : 403, 1943.

5. Dalldorf, G., Gilbert and Kellogg, M. : Incidence of
gastric ulcer in albino rats fed diets deficient in vitamin
111. J. Exper. Med., 56: 391. 1932.

6. Welch. A. D., and Wright. L. D. : The role of “folic
acid” and biotin in the nutrition of the rat. J. Nutrition,
25 : 555, 1943.

7. Cheney, G. : Vitamin 111 and liver extract in the
treatment of non-specific diarrhea and colitis. Am. .T.
Digest Dis., 0: 161, 1939.

8. Chesley, F. F., Dunbar, J., and Crandall, L. A. : The
vitamin B complex and its constituents in functional diges-
tive disturbances, Am. J. Digest Dis., 7 : 24, 1940.

9. Haag, II. B., and Taliaferro, I. : Effect of ascorbic
acid in guinea pig colon, Proc. Soc. Exper. Biol. & Med.,
45 :479, 1940.

O

FILARIASIS

A FUTURE PROBLEM IN THE
UNITED STATES

CHARLES D. KNIGHT, M.D.

Shreveport

With the entrance of the United States
into the present world conflict in 1941,
tropical diseases and tropical medicine
gained a position of importance which they
have never before occupied in this country.
This was the result of the global war which
placed hundreds of thousands of American
service men in tropical and subtropical
countries where these diseases are found
in their most severe forms. And now, after
three years of war, the medical profession
has been duly impressed with this new im-
portance of tropical medicine : not only
those doctors who are in the battle areas
who, of course, were the first impressed
but also the physicians here at home. No
longer are most tropical diseases remote
entities in textbooks, for daily, soldiers,
sailors, and marines are returning to this

country with some form of leishmaniasis,
trypanosomiasis, schistosomiasis, malaria or
filarisis.

It is the purpose of this paper, then, to
present a discussion of one of these timely
diseases — filariasis — in the light of some of
the newer concepts which have been formu-
lated since the beginning of the war, and
more specifically to consider the possibility
and probability of filariasis as a post-war
problem in this country.

There is, perhaps, no tropical disease
which is feared more by the general pub-
lic and the soldier than filariasis. This is
because the only familiar stage of the dis-
ease is the chronic one presenting a pic-
ture of an enlarged scrotum or elephantoid
extremities. It is no wonder, then, that
the services turned to the medical profes-
sion with urgent questions concerning the
prognosis for life, for sexual impotence, and
for permanent disability if they contracted
the disease. But while all these questions
were being considered, an even more sig-
nificant question that lurked in the minds
of many was the possibility of filariasis be-
coming endemic in the United States. They
had not forgotten that just 100 years ago
there was an endemic focus of filariasis at
Charleston, South Carolina.

If then, there are still potentially endemic
areas for the disease in this country, it is
not difficult to imagine the problem that
might be created with new cases of filariasis
returning to this country each week from
the Pacific area. The real scope of this
problem can only be ascertained after we
know the number of cases of filariasis
which have returned to the United States.
Unfortunately, this fact is not available at
the present time but conservative estimates
place the figure at about 7,000 men.

With this problem before us, we will con-
sider filariasis in some detail in an effort
to get an insight into a situation which
theoretically could produce a tremendous
hazard to the health of the American pub-
lic.

general considerations

Under the general term filariasis, there
are included all the morbid conditions pro-

Knight — Filariasis

407

duced by certain parasitic nematodes of the
superfamily Filarioidea, the adults of which
may live in the circulatory or lymphatic
systems, the connective tissues, or serous
cavities, while certain larval forms, called
“microfilariae,” are found in the circulat-
ing blood or in the lymph spaces. In its
broadest sense, the term filariasis implies
infestation of the host with any species of
the superfamily and thus, widely different
pathologic conditions may be included un-
der it. Although more than twenty species
of filariae have been reported for man, only
four are the etiologic agents of important
pathogenic types of filariasis. These agents,
the diseases which they produce and the
vectors are listed below:

Etiologic Agent

1. Wvichereria bancrofti

2. Wuchereria malayi

3. Onchocerca volvulus

4. Loa loa

Disease

Bancroft’s

filariasis

Malayan

filariasis

Onchocerciasis

Loaiasis

Vectors
Mosquitoes
(Culex, Aedes)
Mosquitoes
(Anopheles,
Mansonioides)
Black Gnat
(•Simulium)
Mango Fly
(Chrysops)

Of these pathogenic types of filariasis,
the first, Bancroft’s filariasis is the most
widely distributed and the most important
clinically. Since all the cases of filariasis
reported in this war among American serv-
ice men are thought to fall in this category,
the discussion will be limited to the one
specific condition caused by Wuchereria
bancrofti.

GEOGRAPHIC DISTRIBUTION

Bancroft’s filariasis is found throughout
practically all of the warm regions of the
world. In Europe, it seems to be confined
to Barcelona, Hungary and Turkey, while
in Africa it is seen throughout the central
tropical belt and along the northern coast.
It is found throughout Madagascar, around
the Arabian coast and has extensive distri-
bution in Burma and India. In the Far
East, it is especially prevalent in South
China, extending as far north as the Shan-
tung Province, southern Korea and south-
ern Japan, and southwardly to the Dutch
East Indies and other islands of the Pacific
where in some loqalities, 80 per cent of the
inhabitants are known to be infected. This
condition is reported as far south as Bris-

bane in Australia. Although, the disease is
recorded as widespread in Asia and the
South Pacific, Craig and Faust7 think that
some of these records include or refer to
W. malayi which was first specifically dis-
tinguished in 1927.

Since a large number of the cases seen
among the American service men have come
from Samoa, it is of interest to note that
Hargrave reported that filariasis in Amer-
ican Samoa probably causes greater dam-
age than any other disease by reason of
the disability effect and the undermining
of the general health which may predispose
to other infections. Also, Phelps reported
filariasis as the third cause of death in fre-
quency in American Samoa, the first cause
being tuberculosis and the second pneu-
monia. A survey of the native guard and
civil employees there showed 48 per cent
harboring microfilariae in their blood.

In the Western World, filariasis is com-
mon along the coast of northern South
America, but apparently does not extend
far inland in the Guianas, Colombia, or
Panama. It is common in the Greater and
Lesser Antilles. In the United States,
Charleston, South Carolina, was formerly
an endemic focus of infection. The filaria-
sis cases were authenticated by early work-
ers but in 1915, Johnson found that 19 per
cent of the patients admitted to the Roper
Hospital in Charleston harbored microfil-
ariae in their blood and in 1919 Francis,16
of the United States Public Health Service,
found among 400 individuals living in
Charleston, that 77 were infected with mi-
crofilariae bancrofti. Today, this focus has
disappeared and no new cases have been
reported. South Carolina is not the only
part of the United States, however, where
filariasis has been reported in the past for
Matas, in 1913, reported upon the occur-
rence and treatment of elephantiasis in
New Orleans and a certain number of cases
have been reported among Puerto Ricans
and Jamaicans in New York City.

ETIOLOGY

In all cases of filariasis reported among
military personnel, the etiologic agent has
been W. bancrofti, and W. malayi has not

408

Knight — Filariasis

been identified in any of the patients al-
though its lesions may be identical with
those of Bancroft’s filariasis. For this
reason, this discussion will be limited to
W. bancrofti.

The adult male of this species measures
approximately 40 by 0.1 mm. and the fe-
male about 90 by 0.28 mm. They are
threadlike, creamy white and translucent
and while the head is slightly bulbous, their
terminations are bluntly rounded. The vul-
va in the female is cervical in position and
the uterus, which extends throughout the
greater portion of the body, contains the
ova. These ova are thin ovoidal shells 38
by 25 microns in size and they contain the
young embryos. As they are pushed into
the outer portion of the uterine tubes, these
shells become elongated to accommodate the
uncoiling embryos and become known as
the sheaths of the embryos. After exit from
the parent worm in this form, the embryos
are known as microfilariae and generally
migrate to the blood stream via the lym-
phatics. They measure 127 by 320 microns
in length by 7.5 by 10 microns in diameter
and exhibit considerable motility. They can
be readily seen in preparations stained with
hematoxylin or Giemsa’s solution.

In certain autochthonous infections espe-
cially in China, India, Australia and the
Western hemisphere, the microfilariae ex-
hibit a striking phenomenon referred to as
filarial periodicity. This was first noted
by Manson in 1880 when he observed that
the larvae are found in the peripheral circu-
lation in great numbers during the night,
reaching a maximum between 10 p. m. and
2 a. m., although few or none can be found
during the day. On the other hand, even
prior to the present war, it was known that
in the Philippines, Fiji, Samoa, Takelou,
Wallis and Ellice Islands, where the mor-
phology of the parasite is identical, native
cases manifest no nocturnal periodicity.
This has been borne out by Michael23 and
others in Samoa while studying the native
population as well as the American service
men with filarial manifestations. There
have been numerous attempts to explain
this periodicity and it has been suggested

that it depends upon the sleeping habits
and activity of the definitive host; or that
it is related to the habits of the insect host ;
or that it depends upon a daily cyclic par-
turition of the female filariae with daily
destruction of all the microfilariae. Since
these theories cannot be considered here in
any great detail, suffice to say that the phe-
nomenon has not been explained with full
satisfaction.

MODE OF TRANSMISSION

The parasite causing filariasis requires
an intermediate host for development
through the larval stages. This interme-
diate host then transmits the larvae to man.
In the case of W. bancrofti, the proved
intermediate hosts include 32 species of
mosquitoes and undoubtedly other appro-
priate hosts exist. According to Mumford
and Mohr24 the chief vector of the micro-
filariae with nocturnal periodicity is the
Culex quinquefasciatus while the carrier of
nonperiodic microfilariae is usually Aedes
variegatus. Other common vectors include
Culex pipiens, Aedes rossi, and Anopheles
costalis. The incrimination of these mos-
quitoes as the carriers of microfilariae in
the Pacific island areas has been confirmed
by Michael, Foegel, and Huntington, and
others who have studied the disease among
military personnel in these battle areas.
The mosquito most commonly involved in
Western Hemisphere filariasis is the Culex
and extensive control procedures are re-
sponsible for decreasing the filarial inci-
dence in this part of the world, especially
in Brazil.

The microfilariae pass into the stomach
of the insect with the blood meal and lose
their sheaths in the first two to six hours.
Some of them migrate through the wall of
the proventriculus and cardiac portion of
the midgut and in four to seventeen hours
have reached the thoracic muscles. During
the course of the next five to seven days,
the microfilariae pass through two ecdyses
and mature filiform larvae emerge which
measure 1.4 to 2 mm. by 18 to 23 microns.
This stage is usually completed about the
tenth or eleventh day when the larvae mi-
grate through the hemaeele within the la-

Knight — Filariasis

409

bium of the proboscis. They escape through
the tip of the proboscis most frequently
during its flexure at the time the blood
meal is being drawn and they enter the
skin by active penetration either through
the puncture wound or unbroken skin.

From this point of entrance, the infec-
tive stage larvae pass through the subcu-
taneous tissues and through the peripheral
blood vessels to the lymphatics and lymph
nodes. Here the larvae settle down and
mature, mate and the females parturate. It
is known that after a successful inoculation
of man, the microfilariae, discharged by
recently matured females, may be expected
to appear in the peripheral blood in about
twelve months. Therefore, the incubation
period of the disease was always given at
about twelve months because the mature
worms were the only ones thought to pro-
duce symptoms. This concept has been
somewhat changed in the light of our pres-
ent knowledge because it has been shown
among the American service men in the
Pacific area that the incubation period and
symptom free periods may be concomitant
and shortened to as little as two months.
This is explained by the fact that larvae
probably neither reach the site of maturity
nor become mature before they produce
symptoms. Indeed, it is thought that many
never become mature. The immature worms
gradually accumulate in large lymphatic
vessels or a set of lymph nodes and from
this site, they may initiate symptoms.

PATHOLOGY AND PATHOGENESIS

There are many instances in which the
presence of adult filarial parasites in the
body is recognized by the occurrence of mi-
crofilariae in the blood while the parasites
exercise no recognizable injurious influ-
ences or pathologic changes. On the other
hand, many cases of pronounced pathology
are seen. O’Connor and Hulse28 have shown
that marked pathologic changes associated
with filarial infection may occur in some
patients who have never complained of
symptoms and are unaware of any distur-
bance.

It has been stated that there is a negli-
gible skin reaction at the site where the

mosquito inoculates the infective stage lar-
vae. Napier,26 however, points out that the
skin around where the larvae penetrate
may become thickened, hard and red, and
this condition usually persists for some
days. There is an inflammatory reaction
set up in the lymphatic channels through
which the larvae migrate apparently as a
result of some substance secreted by the
larvae, and the tissues respond by hyper-
trophy of the endothelial cells of the vessel
walls.

After considerable study of the cases of
acute filariasis among the American troops,
Michael23 made specific histo - pathologic
observations. He found that with a living
worm in the lymphatic channel, fibrin is
deposited on the endothelial surface, the
wall of the lymph vessel becomes edema-
tous and markedly thickened and there is
a heavy cellular infiltration of eosinophils.
Degeneration follows and the tissue reac-
tion becomes more specific. Worms rang-
ing from partial degeneration to dead forms
may be seen within the lumen and in the
lymph channel wall. The vessels show a
thickening by proliferation of filarial granu-
lation tissue which is almost pathognomonic
for the condition. Caseating foci of worm
segment are represented by a central core
of necrotic tissue with stellate radiating
proliferations of endothelial cells, fibro-
blasts, epithelial cells, and numerous for-
eign body giant cells. There is a dense
zone of eosinophils surrounding the area.
The granulation tissue is arranged in pali-
sades following wavy undulating pattern.
This distribution conforms to the coiled
segments of the parasite. It was noted that
the calcification observed in degenerated
worms started centrally and proceeded per-
ipherally. The non-specific character of
the granulation tissue has led Michael23
and others to believe that the lymphangitis
is due to a specific allergic reaction in re-
sponse to the worm or microfilariae and a
partial obstruction of the lymphatics.

A different histologic picture was de-
scribed for the lymph nodes involved in this
condition. In the nodes where the parasite
was living and mature, the histologic pic-

410

K N IG H T — Filariasis

lure was distinctive. Worms were present
in the afferent lymphatics or the medullary
sinuses. In most instances, afferent ves-
sels were hyperplastic, forming varices
which extended into the deeper portions of
the lymph nodes. Growing worms held
within these varices were surrounded by a
rather specific type of tissue reaction. A
dense zone of eosinophils surrounded the
worm and a central focus merged into the
edematous lymph follicles with intact ger-
minal centers showing increased mitotic
figures. The plasma cells were increased
in cortical areas and the entire node was
edematous. The enlargement of the node
was believed to be due to the presence of
the parasite, edema and the generalized hy-
perplasia of the node. With degenerative
changes in the worm both the parasite and
the lymphatic tissue of the host show his-
tologic variation. The final outcome is one
of dissolution and absorption of the para-
site, fibrous tissue replacement and disap-
pearance of most of the specific diagnostic
criteria.

The adult filarial worms which degener-
ate and die and are encapsulated within the
lymphatic tissues are thought to discharge
toxic by-products which are in turn prob-
ably responsible for the acute inflammatory
processes which usually develop around
them. These reactions are presumably al-
lergic in type and may be subclinical or
with mild inflammatory manifestations. In
support of this allergic hypothesis Acton
and Rao- reported a series of cases with
urticaria and eosinophilia believed to be due
to filarial infection. This allergic reaction
has been recently restudied by Michael23
among the filarial cases in the American
troops and he thinks that in the develop-
ment of the classical pathologic picture of
filarial involvement of the genitals, with
later destruction, necrosis and even calci-
fication, there is at first a stage of tissue
sensitivity, manifested by edema and peri-
lymphatic cellular invasion, due to the pres-
ence of the worm elsewhere.

It has been pointed out by Napier26 that
the most likely explanation for the period-
icity of the febrile attacks and other aller-

gic signs and symptoms, both local and
general, is that the gravid female gives
birth to living embryos intermittently,
probably a few days each month.

The pathologic processes which are re-
sponsible for clinical manifestations of
filariasis are inflammation and obstruction
of the lymph channels. The inflammatory
processes have been described in detail but
the more serious aspects of this condition
are due to some form of obstruction. The
circulation of lymph in any part may be
obstructed by single or bunches of adult
worms in the lymphatic vessels, large or
small. The blockage may be associated with
little organic reaction or an inflammatory
one may occur such as described above. If
obstruction due to the adult parasites takes
place as high up as the thoracic duct, large
varicose dilations of the thoracic and retro-
peritoneal lymphatics may be produced. A
similar obstruction of abdominal lymphatics
may cause a chyluria if transudation of
chyle through the distended or ruptured
lymphatics into the pelvis of the kidney, the
ureter, or the bladder occurs. In a like
manner, varicose dilations of the lymphatic
vessels of the inguinal, iliac, testicular, sper-
matic regions, and of the skin of the labia
or scrotum may occur. Hydrocele may also
result from filarial infection.

When the lymph flow is obstructed, the
lymph pressure increases, the lymph ceases
to drain from the tissues and the part be-
comes progressively more swollen. In the
course of time, the fibroblasts in the skin
multiply and form new fibrous tissue which
makes the skin dense and hard; the deeper
skin layers involving the sweat glands, in-
terfering with the lymphatics in that re-
gion and producing edema followed by
fibrosis around the sweat glands, which are
eventually destroyed so that the skin in
elephantiasis is harsh and dry. In the
meantime, surface hypertrophy of the epi-
dermis becomes more marked, fissures oc-
cur in the horny layer and allow micro-
organisms to invade the corium. In these
large elephantoid limbs, repeated attacks of
inflammations, originating at the surface
and due to the secondary bacterial infec-

Knight — Filariasis

411

tion, are externally common and increase
the local hypertrophy.

As long as the lymphatic obstruction is
only partial or intermittent, microfiliariae
will find their way into the blood stream,
but if it is complete, the larvae are confined
behind the obstruction in the edematous
and hypertrophic limb and do not appear
in the blood stream. Hence, it is the rule
that in cases of chyluria or lymphatic varix
of the cord, microfilariae are almost always
found in the blood, whereas in elephantiasis
of the limbs and genitalia they are fre-
quently not found.

The importance of secondary bacterial
infection is a controversial subject. It was
thought by Anderson3 and Grace18 that the
lymphatics in filaria-infected individuals
was the result of hypersensitiveness to cer-
tain strains of hemolytic streptococcus.
This belief came about when it was noticed
that in elephantoid limbs, the skin became
stretched and poorly nourished and with
consequent cracking, the invasion by bac-
teria and fungi was comparatively simple.
The controversy which arises is whether
the micro-organisms isolated from the outer
cutaneous layers of these limbs could be re-,
sponsible for the preceding lymphangitis.
Leiper, Acton and Rao are among the work-
ers who agree with the importance of
staphylococcal and streptococcal infections
in filarial attacks. McKinley is opposed to
this concept because he found no evidence
of bacteria in the actual focal centers of the
inflammatory processes. O’Connor27 is one
of the leaders of the school which believes
that most of the mild inflammatory reac-
tions can be attributed to the irritation of
the filarial secretions and of the body itself
and to an allergic response on the part of
the host to these. In regard to this matter,
it is of interest to note that comparatively
few cases of streptococcal contamination
have been encountered in the cases among
the American service men in the South Pa-
cific.

SYMPTOMATOLOGY

The clinical picture of filariasis can best
be divided into four stages. These are:
(1) the incubation period; (2) the patent

symptomless period; (3) the acute stage;
and (4) the chronic stage.

The incubation period is given in most
textbooks as twelve months. "This includes
the time from the entry of the third stage
infective larvae into the skin until micro-
filariae first appear in the peripheral blood.
During this time, there are no known symp-
toms, except for occasional allergic mani-
festations. The second or patent symptom-
less period may last for years or through-
out life and although local tissue alterations
around the adult worms may be in progress,
there are typically no manifest symptoms.
Actually, in the light of recent studies by
Michael and others, it is now believed that
the incubation period and symptom free pe-
riod may be concomitant and symptoms
have been observed in as short a time as
two months after initial exposure.

The occasional allergic reactions which
are the only symptoms or signs seen during
the initial two stages of the disease have
been described by O’Connor et al.2T They
are generally thought to be due to the by-
products of the migrating worms and they
may cause the so-called “fugitive” swell-
ings or lymphangitis. In spite of the fact
that the incubation period may be as short
as two months, it is to be remembered that
a large number of cases will show an essen-
tially symptomless period of months and
years.

The acute stage is the one in which
lymphangitis is the conspicuous symptom.
It is characteristically recurrent and is usu-
ally seen with so-called “filarial fever.”
The lesion is often linear, elevated, hyper-
emic and excruciatingly painful to the
touch. Constitutional symptoms not un-
commonly usher in the attack and these
include chills, mild fever, general malaise,
headache, occasional photophobia, and pains
all over the body. The painful, red swollen
areas in the extremities later involve the
adjacent lymph nodes followed by retro-
grade or centrifugal lymphangitis. The
majority of the patients show funiculitis
with or without epididymitis, orchitis, or
hydrocele. Grace,17 in his studies of tropi-
cal lymphangitis in New Guinea, states that

412

Knight — Filariasis

four-fifths of the patients show involve-
ment of the lower limbs, followed by the
upper limbs, breasts and scrotum. But in
Michael’s series as well as that of Buxton,
and Dickson, Huntington and Eichold,10
highest incidence showed involvement of
the scrotum followed by the upper extremi-
ties and then the lower extremities.

This initial attack lasts for a few days
to weeks and is followed by remissions.
Michael reported that the majority of his
cases had one or more relapses since the
initial attack. During these remissions, the
involved areas may regress and the patients
show few, if any, physical signs. They may
actually enjoy good health during this time
and the periods of remission seem to grow
longer and the duration of relapse shorter
with each subsequent attack.

It is important to remember that it is
this acute stage of recurrent lymphangitis
which has been repeatedly observed among
our service men in the Pacific isles. This
is what the natives call “mumu” and it was
first described by Buxton0 over 20 years
ago.

Another part of the symptomatology of
this disease about which little is said is that
of the psychosomatic manifestations which
have not been uncommon among our troops.
The apprehension of the soldiers and ma-
rines concerning this disease has been quite
noticeable and it is attributed to their see-
ing elephantiasis in its worst form among
the natives and the natural regard which
they have concerning their genitals, and
the possibility of becoming sterile. This
apprehension has led to mental depression
in some cases and the possibility of these
manifestations must be remembered by the
physician and guarded against.

It is the chronic stage of the disease
about which one usually thinks when the
term filariasis is used and although the
acute stage has been long recognized, the
majority of the literature is concerned with
terminal filariasis or elephantiasis." When
the chronic stage of the condition develops,
there is enlargement of the involved organ
or member in an elephantoid type of dis-

ease or the development of lymphocele, fre-
quently with rupture, in the less fibrosed
type. Elephantoid scrota and extremities
may become tremendously enlarged and a
great burden to the patient. The involved
tissue usually consists of lymph and fat in
a fibrous matrix covered by a stretched,
tightened skin. The edema present is non-
pitting in type.

The statistics of Manson-Bahr show that
in 95 per cent of the cases, the lower ex-
tremities are the seat of the disease. It is
usually, but not always, confined to below
the knee. Next to the leg, the scrotum is
most frequently involved and these tumors
may become enormous. Commonly they are
10 to 15 pounds in weight but the largest
one recorded is 224 pounds.

Elephantiasis usually begins as a lym-
phangitis with fever, secondary dermatitis
and cellulitis. The onset may be insidious,
however, with no evidence of lymphangitis
and the condition may develop as a painless
swelling. The regional lymph nodes are
usually enlarged. The general appearance
varies with the age of the condition. In
those of long standing, the skin is thick-
ened and leathery. The subcutaneous tis-
sue is also greatly hypertrophied and the
weight of the part often prevents all but
limited motility. At times a secondary bac-
terial infection supervenes with the produc-
tion of a septicemia.

DIAGNOSIS

The recognition and diagnosis of this con-
dition is often easy, especially in the en-
demic areas. As a matter of fact, the na-
tives in the South Pacific islands make the
diagnosis of “mumu” very readily them-
selves. The early diagnosis is particularly
of importance because this helps the prog-
nosis considerably. One may diagnose ele-
phantiasis due to filaria readily but it has
reached a far advanced stage and nothing
can usually be done. On the other hand,
early filariasis, if properly handled, has a
good prognosis, although no specific ther-
apy has been found.

This condition should always be thought
of in those patients with a history of hav-
ing lived in endemic areas of filariasis ever

Knight-

Filariasis

413

any period of time. Another suggestive fac-
tor is the history of recurrent attacks of
lymphangitis with fever. A history of al-
lergic manifestations is also suggestive but
lymphangitis is the first good sign of the
condition.

Of course, the clinical picture of the con-
dition as described above helps to put one
on the track of the correct diagnosis but it
is agreed that the most valuable single diag-
nostic aid is a blood film. The thick blood
film should be used and the sheathed micro-
filariae of the periodic type can often be
demonstrated in the peripheral blood at
night (10 p. m. to 2 a. m.). In the non-pe-
riodic type these organisms can usually be
demonstrated throughout the 24 hours. It
should be recalled, however, that the micro-
filariae may not always be present because
the parasites may not have access to the
peripheral circulation, due to the anatom-
ical location of the adult or because of the
development of a pathologic sequence which
prevents entrance to the blood stream. The
microfilariae are readily demonstrated in
the blood of the native populations of the
endemic islands showing the effect of long
residence in such an area. Dickson, Hunt-
ington, and Eichold10 showed microfilariae
in thick blood films of 13.6 per cent of the
1,859 natives of Tutuila examined while
only 1.6 per cent of 244 children under five
years of age had microfilariae.

In spite of the fact that blood studies are
by far the best diagnostic aid in filariasis,
they have proved of no benefit in the cases
among American service men. For al-
though careful studies have been carried
out by experienced men on proved soldier
cases, the microfilariae have not as yet
been demonstrated in the peripheral blood.
Michael and his co workers 23 have examined
several thousand thick and thin smears
taken day and night but they all proved
negative for microfilariae. He thinks that
the microfilariae were probably present in
the blood before the clinical symptoms de-
veloped.

The search for -the microfilariae should
not be confined to the blood stream for they
are not infrequently found in the urine,

ascitic fluid or in the puncture of a hydro-
cele.

One of the best methods of diagnosis is
by means of biopsy of lymph channels and
lymph nodes. This was never appreciated
more than in the current cases among the
service men in whom blood studies have
proved nothing. These biopsy specimens
are searched for adult filariae or larvae
and their discovery makes the diagnosis.
A reward of careful searching is seen in
Michael’s series in which isolated foci of
living or dead parasites were demonstrated
in 30 per cent of 120 biopsy specimens and
of these positive biopsies, 70 per cent were
in the peripheral lymph channels, the re-
maining in the lymph nodes. The men who
get the best results with this diagnostic
method suggest detailed study of the biop-
sies not only by hemisection but by cul-
ture, immersing in saline, and by serial
sections. There are some who think that
even though the organism is not found, cer-
tain histologic changes when present sug-
gest a presumptive diagnosis of filariasis.
This is still an unsettled question but fur-
ther histologic studies should give the final
answer.

There is also some controversy about the
best site and time for biopsy. Faust12 and
some other workers do not think that biop-
sies ought to be taken during the acute at-
tack while Fogel and Huntington15 think
that biopsy of the spermatic cord and re-
gional lymphatics is absolutely unjustified.
Michael and his coworkers23 have reported,
however, that removal of the upper extrem-
ity lymph nodes and lymphatics has not
harmed their patients and in some in-
stances, definitely resulted in improvement.
In this matter, too, the final answer will
only come with further study and experi-
ence.

A diagnostic aid of definite value and one
which should not be overlooked is the roent-
genogram to be used in those cases where
death and calcification of the adult worms
has occurred.

Another diagnostic procedure which has
caused considerable controversy is the intra-
dermal reaction as described by Taliaferro

414

K N i c, H T — Filariasis

and Hoffman, and by Fairley.11 An antigen
is used which is prepared from Dirofilaria
immitis as described by Fairley. Until very
recently, the results have not been encour-
aging. As a matter of fact, Hamilton in a
personal communication to Napier,20 basing
his opinion on experience in the East Indies,
considered the positive tests with the anti-
gen of little value since about two out of
three normal natives showed positive re-
sults. He thought that negative tests were
actually of greater value in excluding filar-
ial infection. Recently, however, Hunting-
ton,10 using Dirofilariae immitis antigen
from Samoan dogs, found that 83.1 per cent
of 137 patients showed positive immediate
and delayed reactions while Michael23
found that 87.3 per cent of 307 proved cases
showed a positive skin test. All these pa-
tients at the time of testing, had stool exam-
inations which were negative for other
nematodes. This latter fact is essential in
evaluating the test because the reaction is
a group reaction and is not specific for
Wuchereria hancrofti. An even more re-
cent report of the intracutaneous test as
used by Wartman and King33 on American
troops with filariasis showed positive read-
ings in 90.8 per cent of 164 patients. So
while the exact value of the test is still
debatable, we can say that numerous work-
ers in the field believe that it is of definite
value and certainly warrants further use
and study.

A complement fixation test in which the
antigen is also prepared from the dog
filaria, Dirofilaria immitis, has given fair-
ly reliable results in some hands. However,
the test apparently depends on the worm
being alive and it has proved impracticable
under army field conditions. The technic is
similar to that of the Wassermann reaction
but like the skin test, it is a group reac-
tion and is not specific for W. hancrofti.

The blood picture, while not diagnostic,
is often suggestive and may serve as an
aid. In the absence of intestinal helminth,
the presence of an eosinophilia is of sig-
nificance, particularly when fever is pres-
ent and a chill has occurred, and the ques-
tion of malaria has thus been suggested. A

leukocytosis, such as often occurs in lym-
phangitis and other inflammatory processes
which accompany filariasis and when sec-
ondary bacterial infection is present, may
also aid in excluding malaria. Filariasis
patients present a relative lymphocytosis
but this is true of most people returning
from the tropics. The red blood count in
these patients is usually normal.

PREVENTION

There is considerable that can be said
concerning the prevention of this disease
under ideal conditions. But when we rea-
lize that these conditions do not commonly
exist in the battle zones, we discover the
magnitude of the problem and see why
many of the attempts to control the disease
have proved futile.

Since the microfilariae are mosquito-
borne and the mosquito is necessary for the
infection of man, we can readily see that
prophylaxis should consist of: (1) the de-
struction of the mosquitoes and their breed-
ing places, and (2) protection from the
bites of the mosquitoes. Such a scheme of
prophylaxis naturally necessitates rigid
precautions and it is facilitated by the co-
operation of all persons in the area. While
prophylactic measures have either not been
used properly or have failed in controlling
the disease in some Pacific areas, there is
no reason why they should not prove effec-
tive if carried out adequately and under
conditions such as those seen in most re-
gions of the United States. Therefore, it
behooves us to consider the following points
which have been suggested as an adequate
program in the prevention of filariasis:

1. Avoid association, in so far as possible
with heavily infected populations. This
means in battle areas which are endemic
for filariasis, establishing quarters away
from the the native villages. In this way,
one can avoid contact with the heavily in-
fected mosquito population. It is probably
in this respect that many of the control pro-
grams in the Pacific have been negligent.

2. Individuals harboring microfilariae in
their blood should be protected by screen-
ing. This serves to protect the patients

Knight

Filariasis

415

from reinfection as well as to prevent the
infection of more mosquitoes and eventu-
ally more individuals.

3. Where it is possible, efforts should be
made to reduce the mosquito population by
appropriate control measures. These meas-
ures should include the usual antimalarial
mosquito control measures for the Ano-
pheles and in addition, the disposal of arti-
ficial water containers, and the oiling of
ditches and puddles to control the domestic
Aedes and Culex.

4. In addition, screening, bed nets, mos-
quito repellents and sprays should be used
against the adult mosquitoes. While these
measures can be used on a small scale, they
are somewhat impractical due to the ex-
pense involved when attempted in a large
area. It is believed that the institution of
a program similar to the above would prove
very effective in preventing the occurrence
of filariasis and in controlling its spread
once cases were found.

TREATMENT

The treatment of this condition is more
unsatisfactory than that of almost any other
tropical disease and in spite of the tremen-
dous strides made in the chemotherapy of
other conditions, none has been demon-
strated in filariasis. Since filariasis was
first described, innumerable drugs have
been tried, and while some have been more
promising than others, all that can be defi-
nitely said at present is that treatment with
drugs aimed at eradicating filarial infec-
tion is ineffective. Occasionally the treat-
ment has resulted in a temporary decrease
in the number of microfilariae circulating-
in the blood stream, but the adult worms
were not killed and they continued to pro-
duce microfilariae.

The most promising of the chemothera-
peutic substances are the trivalent antimony
preparations, anthiomaline (lithium anti-
mony thiomalate) and stibophen (fuadin).
These have been tried extensively and it is
thought that they may be of some anti-
filarial value in asymptomatic and selected
early clinical cases. Brown4 recently re-
ported that the former drug was given in-

tramuscularly to a series of filaria infected
patients and their microfilariae count was
reduced 85-100 per cent. Since this reduc-
tion was maintained for four to five months
after the completion of treatment, the au-
thor presumed it to mean that a correspond-
ing number of adult worms were killed.
The actual significance of this work can-
not be appreciated at the present time but
we can only hope that it is either the an-
swer to the chemotherapeutic problem of
filariasis or a step in the right direction.

Several arsenicals which kill the micro-
filariae or prevent their migration to the
peripheral circulation have been used but
they are ineffective against the adult
worms. Sulfonamides have also been tested
and have proved to be without apparent ef-
fect. It seems that their only use lies with
that of autogenous vaccines in the therapy
and perhaps prophylaxis of bacterial com-
plications.

One of the most useful clinical procedures
in treatment of filarial elephantiasis of the
lower extremities, is the pressure bandag-
ing technic of Knott21 using six-inch strips
of bath toweling, painted with dextin strips
and covered with cotton elastic crepe band-
age and an outer muslin bandage to keep
out the dirt. Exercise is required to pre-
vent cyanosis and hasten reduction of lym-
phedema.

Operative procedures are thought to have
a definite place late in the disease, when
elephantiasis is present but they certainly
leave much to be desired and constitute an
admission of the failure of early treatment.
The best known operative procedure is the
modified Kondolean operation which surgi-
cally removes the elephantoid tissue and
thus reduces the size. This reduction in
size is usually temporary and recurrence is
anticipated in the course of five years.

Due to the status of chemotherapy in
this condition, the treatment must be large-
ly symptomatic. For acute lymphangitis
the treatment should consist of bed rest,
elevation of the affected part, and scrotal
support if necessary. Ice is sometimes used
and local compresses of magnesium sulfate
are thought to be helpful. An important

416

Knight — Filariasis

part of this initial therapy, which has been
proved among the soldiers, is reassurance
of the patient — reassurance that the condi-
tion is not as serious as malaria or tubercu-
losis, and that it cannot be transmitted to
his wife and children. Such psychotherapy
may prevent the psychosomatic manifesta-
tions of filariasis.

An important adjunct to the therapy is
the return of the patients to some non-
filarial area because in this way, possibility
of reinfection is lessened. The optimal fac-
tors of tropical humidity and temperature
are removed by change to temperate cli-
mates.

PROGNOSIS

The first question everyone usually asks
about filariasis is concerning the prognosis.
Therefore, with thousands of men return-
ing to the United States with this disease,
it behooves us to understand fully the mat-
ter so that we can prognosticate wisely.

In the first place, the prognosis for life
is generally fair to good. Even if the pa-
tient should develop elephantiasis, apart
from the disability produced, the outlook is
good because the condition is a chronic one
and patients frequently live for years. Such
a prognosis, of course, does not hold in cases
with secondary bacterial invaders which
produce a septicemia.

The acute stage of the disease subsides
after a few days’ rest but the patients
should not return to full duty for 10 to 14
days after an acute attack or even longer if
the scrotum is involved. Even then, the
resumption of activity should be very slow
because recurrences with renewed activity
are not uncommon. It is a well recognized
fact that recurrences are much more com-
mon in Samoa and the other endemic areas
than they are when the patient is moved
back to the United States. This has led us
to believe that the prognosis is much better
if the patient is removed from the endemic
area after an acute attack.

It is felt by Dickson, Huntington, and
Eichold10 that there is little risk of deform-
ity of the legs and arms wTith an acute at-
tack of filariasis but deformity of the scro-

tum has been recorded and the prognosis
in such cases is doubtful. Michael, however,
after careful studies of the pathology of the
acute cases among American troops, stated
that the pathologic lesions appeared to be
reversible and that after the filarial reac-
tion has subsided, even the genital lesions
should return to normal.

One of the important questions consid-
ered in giving a prognosis is the matter of
sterility. Since the pathology is often geni-
tal, it is a natural question to be raised and
this problem often constitutes the major
concern of the young men involved. Unfor-
tunately one cannot say at the present time
with certainty whether this condition will
produce sterility to any appreciable degree,
because no data are available as to the inci-
dence of sterility in filarial epididymitis
and vasitis. We can say, however, that the
native populations in the endemic areas ap-
pear relatively prolific and this fact speaks
against sterility due to filariasis. Michael
thinks that if sterility develops, it should be
of a temporary nature and that the genital
lesions should return to normal.

It seems that a better insight into the
matter can be gained by considering Na-
pier’s25 ideas concerning the disease. He
believes that the psychologic trauma that
our troops have endured far exceeds in seri-
ousness, the somatic trauma ; that they have
seen the bizarre deformities suffered by a
large population of the natives in the hyper-
endemic islands in which they acquired
their own filarial infections and that they
have not unnaturally assumed that their
fate would be the same. He further points
out that due to the weakness of medical
texts to emphasize the extremes of disease,
the ordinary physician is likely to believe
that filarial infection is inevitably asso-
ciated sooner or later with a huge scrotum
or an elephantoid leg, while the contrary
is the truth. In certain endemic areas, for
instance, even though 5 per cent of the na-
tive population may exhibit filarial infec-
tion, only a fraction of 1 per cent shows
gross filarial lesions at any time during
their lives. It is important to remember
that obstruction of the lymphatics of a

Knight — Filariasis

417

whole limb occurs only after repeated heavy
infections over a long period of time.

The question that arises then, which we
must answer, is whether the doctor can
honestly assure returning service men, who
have been subjected to heavy filarial infec-
tion, but for limited periods of time, that
they will not suffer from any serious ele-
phantoid deformities and that their sexual
powers will be unimpaired. After consid-
ering the facts which have been presented,
I agree with Napier that a favorable prog-
nosis can be given this condition with as
much assurance as any medical prognosis
can be given.

FUTURE HEALTH PROBLEM IN UNITED STATES

After reviewing filariasis briefly in the
light of some of the newer concepts which
have been emphasized since our entry into
the war, it seems fitting to attempt to de-
termine the status of the condition in the
United States, not only for today but for
tomorrow as well. We should attempt to
answer the question, “Will filariasis consti-
tute a public health problem in the United
States in the future?”

There is no one who can deny that the
filariasis problem exists as a possibility in
the future. Theoretically we have every-
thing in the United States which is neces-
sary for the condition to become endemic.
The only factors needed for transmission of
the disease are the proper vectors, a source
of microfilariae, and a susceptible popula-
tion. We have many species of mosquitoes
in the United States belonging to the genera
Culex, Aedes or Anopheles which are the
intermediate common hosts and vectors of
the filarial organisms. We also have a
sizable potential source of microfilariae in
the service men returning from the battle
areas and the susceptible population is cer-
tainly provided by the American public.
But in addition to these factors which ful-
fill the requirements for transmission of
filariasis, there is one other item which
points even more conclusively to the condi-
tion as a post-war problem. This is the
fact that there have been proved endemic
foci of the disease within the continental

United States. Such a consideration some-
what removes the filariasis problem from
the realm of pure theory because these foci
show beyond any doubt what can and may
happen in the United States.

But in spite of the fact that all of these
things speak strongly for the possibility of
filariasis as a future problem, there seem
to be even stronger arguments against such
a probability. In the first place, it is im-
portant to note that in those hyperendemic
areas where the disease constitutes a major
health problem, the chronic cases which are
represented by elephantiasis in one form or
another, only result after repeated infec-
tions by a heavily infected mosquito popu-
lation. In other words, the acute cases
which are the variety which have been
brought to the United States, are not
thought to become chronic without addi-
tional reinfection. In fact, some workers
believe that many of the victims of acute
attacks will never have a recurrence. This
conclusion has been reached only after a
careful study of the pathology of the dis-
ease. Michael, for example, believes that
the natural defenses of the body, the re-
moval of the patient from endemic areas,
and the prevention of reinfection will re-
sult probably in the disease running a self
limited course.

One of the most significant arguments
against filariasis as a major health problem
in this country is the fact that numerous
trained workers have searched diligently
for the microfilariae in the peripheral blood
of proved filarial patients without results.
This is an excellent indication that the po-
tential source of microfilariae in this con-
dition may never become an actual one. Of
course, there is nothing definite about this
because most writers agree that in these
patients, the microfalariae have probably
been present at one time or another. The
fact, however, that they have not been dem-
onstrated as yet is certainly hopeful.

It seems that a good approach to this
situation is to study one of the previous
endemic foci in the United States. In
Charleston, South Carolina, for instance, a
definite focus of endemic filariasis was re-

418

Knight — Filariasis

ported by Francis10 in 1919. Of even great-
er significance to the point under consid-
eration is the fact that this focus no longer
exists. For whatever the cause of the dis-
appearance of this focus, it offers a tenta-
tive solution to a future problem should it
become acute. Unfortunately, there does
not seem to be a great deal in the literature
concerning the measures undertaken to con-
trol this focus. It is presumed that the con-
trol was brought about through improved
and rigid mosquito control measures, and
this certainly gives us an idea around which
to build our preventive measures. Un-
doubtedly, however, the fact that the op-
timal factors for the disease (tropical
humidity and temperature) are not present
here in the temperature climates, played an
important part. So, even if foci of filariasis
should develop, they are likely to die out,
just as happened in Charleston where the
focus existed for a century and a half and
yet did not spread to other parts of the
country.

In the light of these arguments, it seems
that we can relegate filariasis as a post-
war problem, to a place of little impor-
tance. But no matter how convincing evi-
dence seems to be against the probability,
we must always keep in mind that estab-
lishment of disease foci here is a definite
possibility. At the same time, we are com-
forted by the fact that mosquito control in
this country is far better than that of any
endemic area of the disease and adequate
mosquito control will not only aid in con-
trolling foci which exist but will also pre-
vent their establishment.

One other matter to be considered in dis-
cussing filariasis as a post-war problem, is
the possibility of individual service men,
who have contracted the disease, becoming
an economic problem to the government. It
has been noticed by some that the men after
an acute attack may have a recurrence of
the symptoms when they resume their nor-
mal activity. How long these recurrences
will continue to take place and whether
they will prevent these men from returning
to normal work after the war is not defi-
nitely known at present. It has been called

to our attention that the recurrences seem
to get further apart and the periods of re-
lapse shorter in duration but the final
answer cannot be given at this time. If
these men were incapacitated due to re-
currence, they would be candidates for pen-
sions from the government and this might
be no small problem at the present rate of
increase of filariasis cases.

SUMMARY

This paper gives a brief discussion of the
geographic distribution, etiology, mode of
transmission, pathology and pathogenesis,
symptomatology, methods of diagnosis, pre-
vention, treatment and prognosis of filaria-
sis, in the light of some of the newer con-
cepts of the disease which have been for-
mulated since the war began.

With these concepts and ideas of the dis-
ease before us, we have discussed the pos-
sibility of filariasis becoming a future
problem in the United States. It is believed
that the possibility of filariasis existing as
a post-war problem is definite because the
United States has all the factors necessary
for the transmission of the disease : suitable
vectors, a source of microfilariae, and a
susceptible population. It is also pointed
out that certain endemic foci of this disease
have already existed in this country.

In spite of these arguments, it is felt
that filariasis will not become an important
or serious post-war problem because: (1)
The source of microfilariae is only poten-
tial, not actual at the present time; (2)
there is little danger of acute cases proceed-
ing to chronic ones here because repeated
reinfections are necessary by a heavily in-
fected mosquito population; (3) acute
cases when returned to this country have
fewer recurrences and fare better than
those remaining in the hyperendemic areas;
and (4) a study of previous endemic foci
in this country show that they died out and
did not spread with the institution of ade-
quate mosquito control.

Therefore, it is felt that filariasis can be
relegated to a place of little importance as
a future problem, although the potentiality
of the disease should not be overlooked.

Knight — Filariasis

419

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25. Napier. L. E. : Filarial infection in returning
service men, Trop. Med. News, 1 :14, 1944.

26. Napier. L. E. : Filariasis due to Wuchcrcria ban-
crofti, Med.. 44:149, 1944.

27. O’Connor, F. IV. : The etiology of the disease syn-
drome in IF. banerofti infections, Tr. Royal Soc. Trop.

Med. & Hyg., 26 :13, 1932.

28. O’Connor, F. IV., and Hulse, C. R. : Studies in

filariasis in Puerto Rico, Puerto Rico J. Public Health &
Trop. Med., 11 :167, 1935.

29. Pasternak, J. G. : Epididymofuniculitis, Arch.
Path., 35 :414, 1943.

30. Rome, II. D., and Fogel, R. II. : The psychosomatic
manifestations of filariasis, J. A. M. A.. 123 :944. 1943.

31. Shattuck, G. C. : Bancrofti filariasis, Med. Clin.

N. A., 27:862, 1943.

32. Strong, R. P. : Stitt's Diagnosis, Prevention and
Treatment of Tropical Diseases, 6th ed., Philadelphia, The
Blakiston Co., 1942.

33. Wartman, IV. B.. and King, B. G. : Early filariasis
in American soldiers, Bull. Lb S. Army Med. Dept., (May)
1944, p. 45.

420

Editorials

NEW ORLEANS

M edical and Surgical Journal

Established 18kU

Published by the Louisiana State Medical Society
under the jurisdiction of the following named
Journal Committee:

Val H. Fuchs, M. D., Ex officio
For two years: G. C. Anderson, M. D., Chairman
Leon J. Menville, M. D.

For one year: J. K. Howies, M. D., Vice-Chairman
For three years: C. Grenes Cole, M. D., Secretary
E. L. Leckert, M. D.

EDITORIAL STAFF

John H. Musser, M. D Editor-in-Chief

Willard R. Wirth, M. D. Editor

Daniel J. Murphy, M. D Associate Editor

COLLABORATORS— COUNCILORS
Edwin L. Zander, M. D.

J. T. O’Ferrall, M. D.

Guy R. Jones, M. D.

T. B. Tooke, Sr., M. D.

George Wright, M. D.

W. E. Barker, Jr., M. D.

C. A. Martin, M. D.

W. F. Couvillion, M. D.

Paul T. Talbot, M. D General Manager

1430 Tulane Avenue

SUBSCRIPTION TERMS: $ 3.00 per year in ad-
vance, postage paid, for the United States; $3.50
per year for all foreign countries belonging to the
Postal Union.

News material for publication should be received
not later than the eighteenth of the month preced-
ing publication. Orders for reprints must be sent
in duplicate ivhen returning galley proof.

Manuscripts should be addressed to the Editor,
H30 Tulane Avenue, New Orleayis, La.

The Journal does not hold itself responsible for
statements made by any contributor.

DEFERMENT OF THE ANNUAL
STATE MEETING

We regret very much that the Office of
Defense Transportation has forbidden the
annual state meeting which was to be held
on April 13. Likewise they have also for-
bidden the holding of the New Orleans Grad-
uate Medical Assembly in the same week.
Of course if the O.D.T. thinks that the hold-
ing of these two meetings will impinge in
any way upon our efforts to win the war,
we gladly acquiesce in their ruling. It does

seem, however, that meetings which are
purely scientific and instructive to the phy-
sician and which in a sense are very largely
local, should not come under the ban of the
Office of Defense Transportation.

The state meeting has not been called off
but has been indefinitely postponed. When
there occurs relaxation in the travel regu-
lations, then there will be a meeting called
by the Executive Committee. In the mean-
time it is to be hoped that the district and
parish medical societies will carry on vig-
orously and actively not only in science but
also in free discussion of the economic and
social problems that face the medical pro-
fession. Never in the history of medicine
of the United States was there a time when
doctors should stick together as closely as
at the present time. We must be prepared
to act as a unit in opposing many of the
projects from the Congress which will re-
sult in loss of our individuality as a profes-
sion and our regimentation as doctors.
o

ANNUAL MORTALITY SUMMARY

It is a remarkable thing that in wartime
when epidemics are more likely to be rife,
when there exists a shortage of physicians,
that the number of deaths in 93 major cities
of the United States decreased almost 4
per cent as compared to the previous year.
Of the 93 cities that reported to the Depart-
ment of Commerce, Bureau of Census, in
the year 1944 there were 468,773 deaths as
compared with 487,931 in 1943. This de-
crease in the total number of deaths was
furthermore notable because in January of
1944 there occurred an epidemic of influ-
enza and pneumonia which very materially
increased the number of people dying in
that month. There were over 4000 more
people who expired this month than would
be anticipated from the three-year average.

It is impossible to compare different
cities because the death rates have not
been computed. As the figures that are
submitted weekly by the city health depart-
ments do not take into account the popu-
lation growth or decline, it is also impos-
sible to evaluate the number of deaths on

Editorials

421

an actual population basis. In many cities
populations have increased materially by
an inflow of war workers from the rural
districts of the country. In some cities
war work has not been carried on to any
very great extent and in some cities the
population has actually diminished.

Although it is not possible to give per-
centage differences for the cities in the
South, it might be of some interest to note
that in nearly all of the Southern cities the
number of people dying has been materially
reduced. In the City of New Orleans there
was a total of 793 deaths in 1944, some 213
less deaths than in 1943. Atlanta, with
a smaller population than New Orleans,
showed a diminution in the number of
deaths amounting to 247. Birmingham had
121 less deaths, Louisville 230, Memphis
153, Nashville 16 and Houston 102. There
were a few Southern cities which showed
an increased number of deaths among their
citizens. This was notable in the two cities
that report from Florida — Tampa and Mi-
ami. In Richmond the number of deaths
increased as it did also in Chattanooga and
Knoxville.

The death rate in New Orleans will al-
ways be higher as contrasted with other
large Southern cities because mortality fig-
ures are tabulated on the basis of the place
of death and not of residence. Many of the
deaths in the City of New Orleans, as is
well known, are of people who have been
imported into the city to be patients/ in the
Charity Hospital. The death rate in New
Orleans will undoubtedly be the lowest it
has been for some years for two prin-
cipal reasons: (1) because there has been
a remarkable population increase on ac-
count of war industries located in the city
and (2) because many fewer people have
been admitted to the Charity Hospital than
when the hospital was at its peak in popu-
lation. The decrease in the number of
deaths in the city reflects credit on the
state and on the municipal health depart-
ments of the state. Also it probably re-
flects the result of the newer chemothera-
peutic agents which have lowered so mate-

rially the number of deaths in people with
certain of the infectious diseases.

Particularly commendable is the lowering
of infantile mortality. There were over
2000 fewer children dying in the 93 cities
that have been tabulated, than in 1943. A
complimentary statement cannot be made
in regard to the infant deaths in New Or-
leans, as there was an increase of 18 deaths
in white infants in the city, or a 2.7 per
cent increase, and 28 more deaths in col-
ored babies, in terms of per cent, 7.7. One
wonders if this infantile mortality increase
in New Orleans may not be due to many
young mothers working in war industries
or in civil occupations who, prior to the de-
mand for labor, would have been at home to
attend to their small children.

o

GRADUATE INSTRUCTION FOR
RETURNING MEDICAL OFFICERS

The young physician who has completed
nine months of internship and then entered
the armed forces feels very definitely that
his training has not been sufficiently ade-
quate to fulfill his needs. The same state-
ment applies to some of the men who had
nine months or even 18 months of training
in one or another of the specialties but who
have not had time enough to qualify them-
selves for a specialty board examination.
The feeling that many of the young medical
men in the armed services have now is that
they will not have had training to qualify
them in a specialty nor will the required
facilities be available to make it possible
for them to have such training if they
want it.

There are also a large number of men
who have been in practice a comparatively
short time who have not had the opportu-
nity of working in Army or Navy hospitals
and who feel that they will need further
training. In this group, as well as in the
group of recent graduates, the fear that
they will have forgotten much of their med-
ical information is certainly distinctly low-
ering to the morale of these medical officers
on duty in the field. However, it may be
said with the utmost confidence that the

422

Editorials

plans which have already been worked out
will provide for nearly every medical offi-
cer who wishes to have either a short or a
long period of further training. To those
who wish three to six months’ refresher
courses, such courses will be given in medi-
cal schools and in the larger hospitals. To
the men who wish to return for more pro-
longed training, notably as residents, the
hospitals throughout the country are pre-
paring to offer very many residencies in
addition to those already established.

The responses to the questionnaire sent
out to the medical officers in the Army and
Navy through the American Medical Asso-
ciation, indicate that in many of the special-
ties, residencies in subjects such as anes-
thesia, dermatology, neurosurgery, neurol-
ogy, psychiatry, pathology and radiology
may be taken care of without extension of
the already existing facilities. On the other
hand, in internal medicine, obstetrics and
gynecology, otolaryngology and most not-
ably surgery, extra residencies will have to
be set up. So far as now ascertainable,
residencies will and can be provided in
number ample to take care of the young-
medical officer who wishes to go into any
of these fields except that of general sur-
gery. It would seem that a very large pro-
portion of young men want to specialize in
surgery. From the present indications
there will not be enough additional surgical
residencies available to begin to take care
of all who wish this training. It is to be
presumed that it may be possible for the
surgical board to reduce the number of
years required for surgical training in or-
der to give opportunity for training to
these surgeons in embryo, particularly in
view of the fact that many of them have
had extensive experience in traumatic sur-
gery. There is one disturbing feature to
which much thought should be given and
that is that about eight out of every ten
young men in the service want to become
a specialist when they finish their tour of
Army duty. From whence will come the
general practitioners of the future?

THE TREATMENT OF VINCENT’S
ANGINA

Vincent’s organisms are commonly found
in the mouth of about 75 per cent of adults.
In the majority of these people there are
no symptoms. In a small group there will
be evidence of a stomatitis and in an even
smaller group there will be an ulcero-ne-
crotic lesion or lesions on the tonsils or on
the buccal mucous membrane. There may
be merely local expressions in these people
but from time to time there is a systemic
reaction associated with fever and the
symptoms that are associated with a rise
in temperature. In a very few instances
the reactions are very severe. This has
been called colloquially systemic or consti-
tutional Vincent’s and from this primary
mouth condition patients may die. It should
be noted also that not only in any dirty
mouth but also in nearly every subacute or
chronic oral condition the Vincent’s organ-
isms will be found, although they may not
be responsible for the mouth lesions. Oral
cancer is an excellent example as is agranu-
locytic angina.

The treatment of Vincent’s angina has
been singularly unsuccessful. Illustrative
of the poor results obtained in the treat-
ment of Vincent’s is the multiplicity of
therapeutic measures that are advocated by
various physicians. In the milder cases
with a marked stomatitis, daily visits to a
dentist with local applications of arsphen-
amine on cotton, between and around the
teeth may be effective, but this is a time-
consuming and prolonged form of treat-
ment.

On account of the difficulty of treating
Vincent’s angina satisfactorily and the un-
satisfactory results that are usually ob-
tained, a very short but well worth-while
report by Lt. Commanders Manson and
Craig* may have been missed by readers
of the Journal of the American Medical
Association. These two Naval officers re-
port on 48 patients with severe angina who

Manson, W. W., and Craig, I. T. : Treatment of
Vincent’s angina with sulfathiazole, J. A. M. A.,
127:277, 1945.

Organization Section

423

were treated with sulfathiazole tablets. The
condition responded promptly to treatment
and recurrences did not occur. The one-
half gram sulfathiazole tablets are allowed
to dissolve in the mouth every two hours
during the day and every four hours at
night. This treatment was continued for
72 hours except in an occasional mild case
when it was continued for only two days.
The author says that the lesions were in-
variably cleared up within a period of 96
hours after the beginning of treatment.

This short report should focus the sulfa
treatment of Vincent’s angina on the mind
of the medical profession. Treatment is
relatively simple and the results are, ac-
cording to the two Naval officers, 100 per
cent perfect. Undoubtedly many members
of the medical profession have made use of
sulfa tablets in mouth conditions but this
report of Manson and Craig is the first to
put on record the successful treatment of
a large number of patients with an often
intractable and difficult lesion to treat.

ORGANIZATION SECTION

The Executive Committee dedicates this page to the members of the Louisiana
State Medical Society, feeling that a proper discussion of salient issues will contri-
bute to the understanding and fortification of our Society.

An informed profession should be a wise one.

THE MEETING OF THE EXECUTIVE
COMMITTEE

The Executive Committee of the Louisi-
ana State Medical Society held a meeting
on February 10. It may be of interest to
members of the profession to know some of
the important transactions that occurred
at this meeting.

The status of the poliomyelitis clinic,
which is being conducted by the Louisiana
State Board of Health at the Charity Hos-
pital in New Orleans, was brought to the
attention of the Executive Committee by
Dr. David Brown, Director of the State
Board of Health. After considerable dis-
cussion the following motion prevailed:
‘That the Executive Committee of the
State Medical Society agrees to the continu-
ance of the poliomyelitis clinic, recommend-
ing that it be placed under the jurisdiction
of Charity Hospital, providing proper fi-
nancing can be done without federal aid.”

Considerable attention was given to the
material which we have been receiving in
our office of the State Medical Society from
Congressional sources and from the Amer-
ican Medical Association’s Committee of
Medical Service and Public Relations, espe-
cially in relation to the various attempts

made by Congress to control various phases
of the practice of medicine. It was felt by
the State Council that a Congressional Com-
mittee should be appointed to review this
material and make appropriate recommen-
dations to the executive officers of the State
Society. It was thought in this manner
adequate opposition could be brought to
bear on bills emanating in Congress antag-
onistic to our idea of the American way of
practicing medicine, and that our Society
would be able to assume a more positive
action in relation thereto. Postwar plan-
ning was discussed very liberally, and a
committee will be appointed to digest and
implement the facts as revealed : First,
from a questionnaire sent to the doctors in
the military service upon their needs on re-
turning to civilian practice ; second, the Bu-
reau of Information of the American Medi-
cal Association in cooperation with the
Office of the Surgeon General of the Army
is sending through our office to every par-
ish a comprehensive questionnaire for fac-
tual data on prevailing conditions as to
medical facilities, hospitals, number of doc-
tors ; third, the State Society will send
out to each doctor of the state a question-
naire to obtain some information as to the
needs of the physicians now in civilian
practice in relation to medical facilities,

424

Organization Section

need for additional medical assistance, and
other recommendations which would be
helpful to the doctors returning from mili-
tary service. You can see from the above
that the Executive Committee is attempting
a serious and conscientious effort to obtain
suitable and accurate data for the aid of
the returning physicians from a profession-
al, educational, and economic viewpoint.
These efforts will be entirely fruitless un-
less we have the assistance of every doctor
in Louisiana. It is felt that all now engaged
in civilian practice would be only too glad
to aid our fighting confreres in getting re-
established in civilian practice.

The following letters in regard to the
postponement of the date of the annual
meeting of the House of Delegates on April
13 are self-explanatory:

Office of Defense Transportation
Washington, D. C.

February 3, 1945
Louisiana State Medical Society
Dr. P. T. Talbot, Secretary-Treasurer
1430 Tulane Avenue
New Orleans 13, Louisiana
Dear Dr. Talbot:

Your application for permit to hold a
conference in New Orleans at the Hotel
Roosevelt on April 13 has been reviewed
by the Committee.

It is the consensus of the Committee that
this meeting should be deferred until such
time as the necessity for the present re-
strictions ceases to exist. Permit is there-
fore denied.

Very truly yours,
(Signed) R. H. Clare, Secretary
War Committee on Conventions

St. Clair Adams and Son
Attorneys and Counselors at Law
New Orleans

February 6, 1945
Dr. Val H. Fuchs, President
Louisiana State Medical Society
New Orleans, La.

Dear Doctor :

Referring to your request for an opinion
with reference to the functioning of the

Association because the United States au-
thorities in Washington have held that your
Association cannot hold its annual meeting,
as provided by Article V of your Charter,
I beg to advise that, in my opinion, the As-
sociation should continue to perform its ob-
jects and purposes with the officers elected
at the last annual meeting until such time
as the Association can hold an annual meet-
ing, in accordance with the terms of its
Charter.

We are in a state of war, as you know,
and the Government has determined that
it is for the general welfare not to permit
the holding of annual meetings and conven-
tions or to otherwise burden transportation
facilities and while it works a hardship
upon many associations similar to yours,
nevertheless it does not in any manner af-
fect the integrity of your Association, be-
cause the subject-matter is completely gov-
erned by the article of your Charter just
referred to, where it is said:

“The officers elected at the last annual
meeting shall hold office under this Char-
ter until their successors are elected and
installed ;***

Under your Charter the officers can only
be elected at an annual meeting and natur-
ally if such a meeting cannot be held they
cannot be elected and consequently this lan-
guage comes into play and the current of-
ficers must continue to act until their suc-
cessors are legally elected and installed, in
accordance with the dictates of an annual
meeting.

With expressions of high esteem and per-
sonal regards, I beg to remain,

Yours sincerely,

(Signed) St. Clair Adams

The Executive Committee adopted unani-
mously this opinion of the Honorable St.
Clair Adams in regard to postponement of
the meeting. Just as soon as the necessity
for this ruling of the Office of Defense
Transportation is removed, the Executive
Committee will arrange for an early date
for a meeting of the House of Delegates, in
order that they may transact the necessary
business of our organization.

Orleans Parish Medical Society

425

Owing to the fact that the date of the
meeting of the House of Delegates is an
uncertain one, the Executive Committee has
requested that each member of the profes-
sion be sent a copy of the financial state-
ment for 1944 and a copy of the budget for
1945. Just as soon as this material can be
correlated in ah appropriate form it will be
sent, and it is hoped that you will take the
occasion to review same.

We are thus confronted with the great
problem of carrying on our organization
under the trying circumstances of a delay
in the usual performance and transactions
of business by the House of Delegates. It
is therefore imperative that the individual
doctors in our parish and district societies
try in every manner to help to maintain
and also to perfect suitable plans for the
great work ahead of us. This is a time
when our parish and district societies
should, if possible, meet regularly and to
have on their programs topics concerning
medical service of the future or other vital
medical subjects for the welfare of our or-
ganization and the civilian population.

Without any attempt to direct or impose
any particular subject, we would like to
take the opportunity of directing your at-
tention to a few things which could be dis-
cussed profitably by the parish and district
societies. One of the most important is the
postwar plan which was spoken of in the
above resume. Another is the question of
establishing in our state some form of vol-
untary prepayment medical insurance. This
subject is receiving the attention of a very
active committee, and it is known that they

were prepared to make a very instructive
report to the House of Delegates on this
vital subject.

There are many matters of national in-
terest emanating from Congress. In the
Organization Section of February, we
brought to your attention the introduction
in Congress of H. R. 395 bill by Represen-
tative Dingell. It should be of interest to
you to know that recently there was intro-
duced by Representative A. L. Miller of Ne-
braska H. R. 1391, a bill to create a Depart-
ment of Health in the Cabinet. It is be-
lieved that the medical profession is vitally
interested in this bill, as it attempts to es-
tablish in the Cabinet a health officer,
which for many years has been the object
of the medical profession of this country.
An antivivisection bill, H. R. 491, should re-
ceive our opposition as it attempts to make
it impossible to carry on animal experi-
ments in the District of Columbia. In the
February issue of the Journal we mentioned
the Pepper report which represented the
views of a Sub-committee of Postwar Edu-
cation and Health of the Senate. It might
be of interest to know that springing from
this report is the Senate Bill 191 known as
the Hill-Burton bill implementing the Pep-
per report. This legislation, if passed, at-
tempts to make a survey of medical and
clinical facilities over the United States,
construction of hospitals and needed beds,
all at a state level. These measures spoken
of above are very vital to the medical pro-
fession, and every doctor should contact his
representatives and senators expressing his
views concerning same.

■o

TRANSACTIONS OF ORLEANS PARISH MEDICAL SOCIETY

CALENDAR OF MEETINGS

March

14.

March

1.

Clinico-pathologic conference,

Touro

Infirmary, 12:00 noon.

March

5.

Board of Directors, Orleans

Parish

Medical Society, 8 p. m.

March

6.

Eye, Ear, Nose and Throat

Staff, 8

March

15.

p. m.

March

7.

Mercy Hospital Staff, 8 p. m.

March

12.

Scientific Meeting, Orleans

Parish

March

16.

Medical Society, 8 p. m.

March

19.

Woman’s Auxiliary, Orleans Parish
Medical Society, Orleans Club, 3

p. m.

Clinico-pathologic conference, Marine
Hospital, 7 : 30 p. m.

Touro Infirmary Staff, 8 p. m.
Clinico-pathologic conference, Touro
Infirmary, 12:00 noon.

I. C. R. R. Hospital Staff, 12:30 p. m.
Hotel Dieu Staff, 8 p. m.

426

Louisiana State Medical Society Neivs

March 20.
March 21.
March 22.
March 23.
March 27.
March 28.

March 29.
March 30.

Charity Hospital Medical Staff, 8 p. m.
Charity Hospital Surgical Staff, 8 p. m.
DePaul Sanitarium Staff, 8p.m.

L. S. U. Faculty Club, 8 p. m.

Baptist Hospital Staff, 8 p. m.
Clinico-pathologic Conference, Marine
Hospital, 7:30 p. m.

French Hospital Staff, 8 p. m.
Clinico-pathologic Conference, Touro
Infirmary, 12:00 noon.

New Orleans Hospital Dispensary for
Women and Children Staff, 8 p. m.

ence at Columbus, January 13. In the fifty-year
history of the association Dr. Smith is the first
representative of a Southern university to occupy
the top executive position.

The Southwest Allergy Forum will hold its an-
nual meeting at the Jung Hotel on April 9-10.

Dr. Hilliard E. Miller attended the meeting of
the American Gynecological Club in Baltimore,
February 23-25. Dr. Miller is president of this
organization.

During the month of February the Society held
one regular scientific meeting. The following pro-
gram was presented: Malignant Diphtheria — A

Case Report by Dr. Charles L. Cox; A Case of Rec-
tovaginal Fistula by Dr. Robert F. Sharp; Tem-
poral Approach in Depressed Fracture of Malar-
Zygomatic Compound by Dr. Waldemar R. Metz;
Fever of Psychic Origin by Dr. Oscar W. Bethea;
A Case of Perirenal Abscess by Dr. E. A. Ficklen;
An Unusual Case of Ureteral Calculi — Five Stones
in One Ureter by Drs. Hugh T. and W. D. Beacham.

NEWS ITEMS

Dr. Theo J. Dimitry was one of ten Loyola
faculty members to receive a citation for services
to that university for over twenty-five years.

Dr. Frank E. Lamothe was recently elected as-
sistant rabban of Jerusalem Temple of the Shrine
for 1945, and Dr. Abe Mattes was elected high
priest and prophet.

Dr. Henry Ogden recently attended a meeting of
the American Academy of Allergists in New York.

Dr. Daniel N. Silverman spoke on the import-
ance of the role of protein and vitamin therapy
in gastro-enterologic disorders at the monthly
meeting of the New Orleans Dietetic Association
recently held at Charity hospital.

Dr. H. Ashton Thomas and Dr. Louis A. Wilen-
sky recently received certifications by the Board of
Otolaryngology.

At a recent meeting of the Orleans Parish School
Board Dr. Emile A. Bertucci, Sr. was promoted
from examining physician to director of field ac-
tivities in the Department of Hygiene and Child
Welfare, New Orleans Public Schools.

At the January quarterly meeting of the Catho-
lic Physicians’ Guild the following officers for
1945 were elected:

Dr. Edwin L. Zander, president; Dr. N. F. Thi-
berge, vice-president; Dr. Theo F. Kirn, secretary;
Dr. P. A. Boudreaux, treasurer; Drs. Joseph A.
Danna, E. L. Leckert and E. J. Richard to the
executive committee; Dr. Henry Ogden, chairman
of membership committee; Dr. Ruth Aleman, chair-
man of. activities.

Dr. Frank Chetta was installed as president of
the medical staff of Hotel Dieu at the annual dinner
meeting held January 15. Other officers installed
were: Dr. Lueien A. Fortier, vice-president; and
Dr. Hugh T. Beacham, secretary-treasurer; Dr.
W. A. Gillaspie, Dr. Monte F. Meyer and Dr. C.
Walter Mattingly, members of the board. Dr.
Chaille Jamison, the retiring president, was toast-
master for the dinner.

Dr. N. J. Tessitore was installed as president of
the staff of Mercy hospital at the annual dinner
meeting held January 3. Other officers installed
were: Dr. William H. Roeling, vice-chairman; Dr.
C. J. Vedrenne, secretary; and Dr. Everett L.
Drewes, treasurer; Dr. R. J. Mailhes and Dr. Louis
Monte, members of the board.

Dr. Wilbur C. Smith was elected president of the Dr. Edmund Connely was recently appointed as
National Collegiate Athletic Association at the city alienist and ex-officio head of the city hospital
closing session of the association’s annual confer- for mental diseases.

■O

LOUISIANA STATE MEDICAL SOCIETY NEWS

CALENDAR

Society
East Baton
Morehouse

PARISH AND DISTRICT MEDICAL SOCIETY

Date

Rouge Second Wednesday of every month

Second Tuesday of every month

MEETINGS

Place

Baton Rouge
Bastrop

Orleans

Ouachita

Rapides

Second Monday of every month
First Thursday of every month
First Monday of every month

New Orleans

Monroe

Alexandria

Louisiana State Medical Society News

Sabine

First Wednesday of every month

Second District

Third Thursday of every month

Shreveport

First Tuesday of every month

Shreveport

Vernon

First Thursday of every month

ASCENSION PARISH MEDICAL SOCIETY
At a recent meeting of the Ascension Parish
Medical Society the following officers were elected
for the year 1945 : President, Dr. E. S. Kyes,

Dutch Town; Vice-President, Dr. Dawson T. Mar-
tin, Donaldsonville; Secretary-Treasurer, Dr. E.
A. Schexnayder, Donaldsonville; Delegate, Dr.
Percy LeBlanc, Donaldsonville; Alternate, Dr.
Myer Epstein, Gonzales.

ASSUMPTION PARISH MEDICAL SOCIETY
The following officers were elected for the year
1945 by the Assumption Parish Medical Society:
President, Dr. Henry A. LeBlanc, Paincourtville;
Vice-President, Dr. H. C. Dansereau, Labadieville;
Secretary-Treasurer, Dr. Julius W. Daigle, Pain-
courtville; Delegate, Dr. Julius W. Daigle; Alter-
nate, Dr. C. S. Roger, Napoleonville.

CALCASIEU PARISH MEDICAL SOCIETY
The Calcasieu Parish Medical Society met on
Tuesday, January 9, 1945, at 7:30 p. m. at the
St. Patrick’s Hospital, and the following officers
and delegates were elected unanimously for 1945:
President, Dr. W. A. K. Seale, Sulphur; Vice-
President, Dr. W. P. Bordelon, Lake Charles;
Secretary-Treasurer, Dr. Eleanor Cook, Lake
Charles; Delegate, Dr. G. C. McKinney, ;Lake
Charles; Dr. W. A. K. Seale, Sulphur; Alternates,
Dr. W. G. Fisher and Dr. Walter Moss, both of
Lake Charles.

LAFAYETTE PARISH MEDICAL SOCIETY
Newly elected officers of the Lafayette Parish
Medical Society for 1945 are as follows: President,
Dr. L. A. Prejean, Scott; Vice-President, Dr. C.
J. Saloom, Lafayette; Secretary-Treasurer, Dr.
A. A. deMier, Lafayette; Delegates, Dr. E. E.
Guilbeau, Carencro and Dr. Paul Kurzweg, La-
fayette; Alternates, Dr. J. M. Miles, Lafayette
and Dr. L. O. Clark, Lafayette.

SHREVEPORT MEDICAL SOCIETY
The following are the newly elected officers of
the Shreveport Medical Society for 1945: President,
Dr. W. R. Mathews; First Vice-President, Dr. J.
E. Heard; Second Vice-President, Dr. C. H. Webb;
Secretary, Dr. T. B. Tooke, Jr.; Treasurer, Dr. E.
B. Flake; Historian, Dr. J. M. Bodenheimer; all
of Shreveport.

ST. MARTIN PARISH MEDICAL SOCIETY
At a meeting of the St. Martin Parish Medical
Society held on January 19, Dr. J. L. Beyt of St.
Martinville was elected president, and Dr. S. D.

Yongue of Breaux Bridge was elected secretary-
treasurer for 1945.

LAFOURCHE PARISH MEDICAL SOCIETY

On January 24, 1945, at Delaune’s Restaurant,
Lockport, La., a regular meeting of the Lafourche
Parish Medical Society was held.

The program was begun by the election to mem-
bership in the society of Dr. Tom Kleinpeter of
Thibodaux, La. and Dr. Philip Robiehaux of Race-
land, La.

This was followed by election of officers for the
year 1945. The following members were elected:
President, Dr. J. L. Danos; Vice-President, Dr. L.
Chatelain; Secretary-Treasurer, Dr. P. A. Robi-
chaux.

Dr. T. Benton Ayo was elected as delegate to
the state convention with Dr. L. J. Kerne as al-
ternate.

A discussion in regard to the merits of the
association of American Physicians and Surgeons
Inc. followed. It was decided to await until after
the State society meeting before formulating a
parish policy in regard to the above.

A motion by Dr. J. L. Danos to write the A. A.
P. S. of the intentions was passed.

By unanimous vote a motion was passed to
contact the state society requesting inactive mem-
bership for Dr. P. J. Dansereau who had been
Secretary-Treasurer of the society since 1918.

Roll Call: Dr. T. B. Ayo, Dr. Charles J. Barker,
Dr. C. Chatelain, Dr. J. L. Danos, Dr. Guy Jones,
Dr. L. J. Kerne, Dr. P. A. Robiehaux.

Dues for local chapter of $1.00 were paid by the
above.

There being no further business the meeting was
adjourned.

Philip Robiehaux,
Secretary-Treasurer.

FIFTH ARMY NEWS RELEASE
TULANE-SPONSORED HOSPITAL IN ITALY
AWARDED FIFTH ARMY PLAQUE
With the Fifth Army, Italy — The 24th General
Hospital, created in New Orleans, Louisiana, by
Tulane University School of Medicine, recently
was awarded the Fifth Army Plaque and Clasp
for exceptionally meritorious performance of duty
in the Italian Avar theater.

The citation accompanying the award, signed by
Lieutenant General Mark W. Clark, 5th Army
Group commander, stated:

“This organization provided superior medical
attention to thousands of Fifth Army troops. The
24th General Hospital maintained highest stand-

428

Louisiana State Medical Society News

ards of professional treatment despite heavy
emergency demands which were made repeatedly.
The noteworthy accomplishments of this hospital
reflect the high traditions of the Medical Corps of
the United States Army.”

The hospital unit is commanded by Colonel Wal-
ter C. Royals, 60 Farnham Place, New Orleans, a
graduate of the Tulane medical school. Most of-
ficers of the hospital are former faculty members
or graduates of the Tulane school, and the ma-
jority of its nurses formerly practiced at either
Charity Hospital, New Orleans, or Touro In-
firmary, in the same city.

SYMPOSIUM OF TUBERCULOSIS
There was to have been held in New Orleans on
April 17-19, a symposium on tuberculosis which
was to have been participated in by numerous
well-known students of this disease. Dr. Chester
A. Stewart was in charge of the program, and
he had secured a group of men well-known
throughout the country for their studies on tuber-
culosis. The symposium was sponsored jointly by
the Louisiana State University School of Medi-
cine, the National Tuberculosis Association, the
Tuberculosis Control Division of the United States
Health Service, and the Louisiana State Tuber-
culosis Association. The meeting promised to be
of great importance, but unfortunately, in spite of
the fact that the number of guests was to be lim-
ited to thirty-nine, the ODT ruled that the meet-
ing- could not be held.

TOURO INFIRMARY

The regular meeting of the Medical Staff of
Touro Infirmary was held on Wednesday, February
14 at 8 p. m. The first presentation on the pro-
gram was a clinico-pathologic conference led by
Dr. Thomas Findley.

This was followed by a symposium on penicillin.
Dr. Rawley M. Penick first presented a report of
the penicillin committee and then the superinten-
dent, Dr. Lewis E. Jarrett, discussed penicillin ra-
tioning. Following these discussions a symposium
on surgical infections, medical conditions, penicillin
in gynecology and obstetrics, in otolaryngology, in
genito-urinary condition and in pediatrics was pre-
sented by Drs. Rawley M. Penick, Manuel Gard-
berg, Hilliard E. Miller, Harold Kearney, Melvin
Gold and J. D. Russ, after which there was a gen-
eral discussion of the use of penicillin.

The program was completed by a talk from Mr.
J. B. Rivers of Mead’s on the composition and use
of amigen in medical and surgical procedures.

SOUTHERN BAPTIST HOSPITAL

The Southern Baptist Hospital staff presented
a program which was given before the Orleans
Parish Medical Society on Monday, February 12.
Those appearing on the program included Drs.
Charles L. Cox, Robert F. Sharp, Waldemar R.

Metz, Oscar W. Bethea, E. A. Ficklen, Hugh T.
Beacham, and W. D. Beacham.

The regular monthly clinical staff meeting was
held on January 23 at 8 p. m. The program con-
sisted of a paper entitled Observations on Uses
of Thiouracil by Dr. P. M. Tiller. Dr. W. H. Gil-
lentine gave a case report on Renal Complications
of Sulfadiazine. Succeeding these presentations
came the monthly death report by Dr. J. W. Wells,
which was followed by election of officers, the
following members of the staff being elected: Dr.
Sam Hobson, chairman; Dr. John T. Sanders,
vice-chairman; Dr. J. W. Wells, treasurer, and Dr.
W. H. Gillentine, secretary.

NEWS ITEMS

Dr. Harry A. Davis, Associate Professor of Sur-
gery, Dr. John S. LaDue, Assistant Professor of
Medicine, Louisiana State University School of
Medicine on the Louisiana State University Unit
at Charity Hospital attended the regional meeting
of the American Federation for Clinical Research
held in Dallas, Texas, February 2 and 3, 1945. Dr.
Davis presented a paper entitled “A comparative
study of thrombo-angitis obliterans in white and
negro patients”; Dr. LaDue talked on “Possible
explanation of the mechanism of compensation of
the failing human heart”; and Dr. Levy gave a
paper concerning “Results in the treatment of
subacute bacterial endocarditis employing com-
bined penicillin and heparin therapy”.

Dr. Edgar Hull, Professor and Director, Depart-
ment of Medicine, and Dr. Louis Monte, Clinical
Associate Professor of Medicine, Louisiana State
University School of Medicine attended the Re-
gional Meeting of the American College of Phy-
sicians ati Memphis, Tennessee.

Dr. Hull who is College Governor for Louisiana
presented a paper entitled “Bacterial Endocardi-
tis” and presided at the afternoon session.

The Director of the Pan American Sanitary Bu-
reau advises, at the request of the Cuban Embassy
in Washington, that the Second National Cancer
Congress will be held in Havana May 5-21, and
the Organizing Committee extends a most cordial
invitation to any American physicians who may
wish to attend and especially to those interested in
this disease.

UNDULANT FEVER

The Journal is in receipt of a letter from
Charles M. Jacob, D. V. M., Convent, Louisiana,
in reference to the article which was published
in the Journal by Dr. Harry J. Schmidt. Dr. Jacob
points out that his own son has undulant fever;
that it is an extremely severe disease; and that
there should be extensive research in the pro-

Louisiana State Medical Society Neius

429

gram of brucellosis so that a cure could be found
for the disease.

Dr. Jacob also points out that Bang’s disease
is very prevalent in the parish and that the peo-
ple should not be allowed to drink raw milk. He
says that every milch cow should be tested for
tuberculosis and Bang’s disease “as soon as a
calf is born.”

NEED FOR PHYSICIANS IN THE NAVY

The serious need for physicians in the U. S.
Naval Reserve is emphasized in recent communica-
tions from the Bureau of Naval Personnel of the
Navy Department.

Since the Army discontinued the commissioning
of physicians, it was anticipated that the procure-
ment of physicians by the Navy would be in-
creased. Actually the number of physicians com-
missioned in the U. S. Naval Reserve has been
decreasing. Three thousand physicians are need-
ed as soon as possible to ease the emergency which
now exists. Even this number will not actually
satisfy the demand.

Your state has already contributed more than
its share of physicians to the various services, but
it is necessary to secure every physician who is
not absolutely essential to the health and welfare
of your state.

Many physical defects may be waived for com-
mission in the U. S. Navy Medical Corps Reserve.
This is being done in order to help fill the urgent
need for medical officers. The age limit is now
55. Doctors up to the age of 60 may apply for
commission and be assigned to the U. S. Veterans
Administration. Rank is based on both age and
experience.

Any applicant should consult the State Chair-
man of Procurement and Assignment Service for
Physicians regarding his possible release and then
contact the Director of Naval Officer Procure-
ment, 611 Gravier St., New Orleans, La.

o

FROM THE LOUISIANA NURSING COUNCIL
FOR WAR SERVICE

TO THE LOUISIANA STATE MEDICAL
ASSOCIATION

Louisiana physicians and surgeons are in a
strategic position as recruitment agents for new
nurses.

On June 15, 1943, the U. S. Cadet Nurse Corps
was created by unanimous vote in both houses of
Congress, to be administered by the U. S. Public
Health Service, for the purpose 'of recruiting 125,-
000 new student nurses in a two-year period. In
its first year the Corps exceeded its goal of 65,000
new nurses by more than 500. This partially re-
lieved the acute nurse shortage. However, 65,000
new nurses will not be enough to combat short-
ages which still exist in every branch of nursing.
In the coming year the additional 60,000 must be

recruited if adequate health care is to be given
our military and civilian population.

Physicians and surgeons have been seriously
concerned with the nurse shortage. Their realiza-
tion of the need should insure their whole-hearted
cooperation with the Cadet Nurse Corps program
and their support in recruiting new students.
Recognizing the fact that if a recruitment cam-
paign for new student nurses is to be effective
it must have the participation of all interested
groups, the American College of Surgeons has
been enthusiastic in its cooperation. Through this
organization, physicians and surgeons have been
urged in every possible way to coordinate their
efforts with the nursing profession, hospitals and
lay organizations in disseminating information
about the Corps program.

At present the Corps fulfills three functions.
It offers the means of recruiting new student
nurses, prepares them more rapidly under the
accelerated program, and provides technic for
distributing nursing service, a system whereby
everyone benefits, including physicians and sur-
geons, hospitals, the new student nurses and the
public.

As a physician or surgeon your contacts are
valuable to the program because you have the
trust and confidence of your patients and you
are often asked for advice by young women inter-
ested in nursing. By giving full information about
the Corps program and by directing these pros-
pective applicants through the proper channels
to the school of their choice, you can help build
up the Corps.

Your aid is needed more than ever as the Corps
enters its second year. Every physician and sur-
geon realizes that he is a potential recruitment
agent for a program in which his own welfare is
vitally concerned.

The Louisiana Nursing Council for War Serv-
ice earnestly asks your sincere support and effort
in securing our state’s quota of new student
nurses and your words of encouragement for the
young women in your hospitals who wear the gray
and red of the U. S. Cadet Nurse Corps.

INFECTIOUS DISEASES IN LOUISIANA

The morbidity report of the Louisiana State
Department of Health showed that for the first
week in January there were reported the follow-
ing diseases in numbers greater than 10: Pulmo-
nary tuberculosis 46 cases, malaria 23, unclas-
sified pneumonia, influenza, and chickenpox 21
each, with 13 cases of scarlet fever. One case
of poliomyelitis was found in Lafayette Parish
this week, and eight cases of typhus fever scat-
tered all over the state. For the next week which
came to a close on January 13 pulmonary tuber-
culosis again led reportable diseases with 45 cases,
followed by 36 of malaria, 31 of chickenpox, 21
of scarlet fever, 20 of mumps, 18 of measles, and

430

Louisiana State Medical Society News

15 of unclassified pneumonia. Most of the cases
of malaria, 34 in number, were reported from
military sources. For the week which ended on
January 20 again pulmonary tuberculosis led all
other reportable diseases with 39 instances, fol-
lowed by 15 of scarlet fever, 12 of malaria, 11 of
measles, and 10 of unclassified pneumonia. This
was a remarkably quiet month, evidently logically
speaking, as all of the contagious and infectious
diseases were remarkably low in their incidence.
For the week which came to an end January 27,
there were reported the following diseases in num-
bers greater than 10: Pulmonary tuberculosis 39,
scarlet fever and malaria 26 each, unclassified
pneumonia 19, chickenpox 17 and influenza 12.
The week which finished the month of January
showed the inclusion of the accumulated venereal
disease reports for the month. This will be first
given. There were listed 1,517 cases of gonor-
rhea, 864 of syphilis, 29 of chancroid, 15 of
lymphopathia venereum, and 11 of granuloma in-
guinale. About half of the cases of gonorrhea
came from military sources as did 96 of the cases
of syphilis. The other reportable diseases listed
this month include 57 cases of chickenpox, 45 of
malaria, 39 of pulmonary tuberculosis, 14 each
of scarlet fever and unclassified pneumonia, 13 of
measles, and 10 of mumps. Forty-five of the
cases of malaria were reported from military
sources, and in 28 of these reported cases the
malaria was contracted outside the Continental
United States.

o

HEALTH IN NEW ORLEANS

The Bureau of the Census, Department of Com-
merce reported that during the week ending Jan-
uary 13 there occurred in the City of New Orleans
154 deaths, many more than the week previous
when only 115 of our citizenry expired. The divi-
sion between the two races was 102 white, 52
non-white, with 13 of these deaths occurring in
children under one year of age. For the succeed-
ing week the number of deaths was 160, of which
106 were white and 54 were colored, with six
infant deaths. The week which closed January
27 showed that 162 people died in the City of
New Orleans, 100 of whom were white and 62
were colored, and in this total deaths there were
nine children under one year of age. This corre-
sponds very closely to a three-year average in
the corresponding week in the year. For the week
which came to a close on February 3 the 152
deaths in the city were apportioned 104 white,
48 colored, with 12 deaths in children under one
year of age.

o

MONTHLY STATISTICAL REPORT
JANUARY, 1945

Estimated Population as of July 1, 1944

White 391,000

Colored 169,000

Total 560,000

Total deaths, all causes 694

White - 452

Colored ., 242

Resident deaths, all causes 363

White - 375

Colored 188

DEATH RATES

(Per 1000 per annum for the month)

All

Non-residents

Deaths

excluded

White

13.8

11.5

Colored

17.2

13.3

Total

14.8

12.1

Total births recorded 1,460

White 994

Colored - 469

Resident births 1,149

White 790

Colored 359

BIRTH RATES

(Per 1000 per annum for the month)

All

Non-residents

Births

excluded

White

30.4

24.2

Colored -

33.3

23.7

Total

31.3

23.9

DR. WESTON P. MILLER
(1886-1944)

Dr. Wester Peter Miller of Eunice, Louisiana,
was born in 1886 and graduated from the School
of Medicine, Tulane University, in 1909. Dr.
Miller died in Touro Infirmary at New Orleans
on October 28, 1944.

DR. CHARLES Y. SEAGLE
(1877-1945)

Dr. Charles Y. Seagle of Bertrandville died at
Baptist Hospital, New Orleans on January 29,
1945, at the age of 67. He practiced for many
years in Plaquemines and St. Bernard parishes
and was the only physician from Arabia to Pointe
a la Hache. The difficulties encountered in Dr.
Seagle’s area were great. He had his own ferry
boat to get to the other side of the river. He had
to do most of his traveling on horseback and was
said to have kept horses scattered around various
places so "that he could get a fresh one when
needed on a long trip. Men such as Dr. Seagle
are few and far between. It will be hard to re-
place him professionally and in the love of his
swamp-living clientele.

Book Reviews

431

BOOK REVIEWS

Familial Susceptibility to Tuberculosis: By Ruth

Rice Puffer, Dr. P. H. Cambridge, Harvard

Univ. Pr., 1944. pp. 106. Price, $2.00.

This small book is essentially a thesis submitted
to the Harvard School of Public Health and based
upon the studies of the epidemiology of tubercu-
losis carried on for eleven years in Williamson
County by the Tennessee Department of Health.
It is a thesis in the original meaning of the word,
maintaining the proposition that heredity plays as
important a part in the development of tubercu-
losis as does infection. Dr. Puffer reviews the
previous work in this field thoroughly and then
gives a statistical analysis of the results of the
Williamson County study of twins, siblings, mari-
tal consorts and parents. Numerous tables and
charts are used to condense these results.

Some very interesting and practical conclusions
are drawn. The decline in tuberculosis mortality
during the past century is statistically explained
by the gradual elimination of susceptible families.
Marital tuberculosis is thoroughly discussed and
the danger of marriages between individuals with
a family history of tuberculosis is pointed out.
The importance of a lifelong study of the children
of tuberculous parents is clearly demonstrated.
Finally, the application of this concept of familial
susceptibility to tuberculosis control is outlined to
point out the most economical field for case finding
in the prevention of this disease. For the statis-
tician there is an appendix with more detailed
tables and the statistical methods used. There are
a good bibliography and an index. Those inter-
■ested in the epidemiology of tuberculosis and its
control will find this a thought provoking and
valuable book.

J. L. Wilson, M. D.

A Bibliography of Aviation Medicine, Supplement;
comp. By Phebe Margaret Hoff, Ebbe Curtis
Hoff, and John Farquhar Fulton. Washington,
D. C., National Research Council, 1944. pp. 109.
Price, $2.00.

This supplement continues the splendid work of
the authors in bringing together the pertinent
references to articles published during the two
years since the original Bibliography was pub-
lished. The authors point out in their preface that
the literature of the past two years indicates an
emphasis on practical problems. This has necessi-
tated the inclusion of a new subheading on “Sur-
vival and Rescue”, many new references dealing
with the transport of sick and wounded by air. A
new subheading on “Rehabilitation” has also been
added. Since aviation medicine overlaps so many
fields, the list of references includes many which
should be of interest £md value to the general prac-
titioner as well as to the investigator.

H. S. Mayerson, Ph. D.

Manual of Clinical Mycology : By Norman F. Co-

nant, Ph. D., Donald S. Martin, M. D., David T.

Smith, M. D., Roger D. Baker, M. D., and Jasper

L. Callaway, M. D. Philadelphia, W. B. Saun-
ders Co., 1944. pp. 348. Price, $3.50.

This new manual on human diseases due to fungi,
prepared by a group of well-known Duke Univer-
sity workers, summarizes admirably and com-
pactly the salient features of modern knowledge
concerning both clinical and laboratory aspects of
the subject. It is a most valuable addition to the
existing literature in the field and should have a
deservedly large circulation, particularly among
those who are not experts but who require a useful
source of reference for aid in the study of sus-
pected mycoses. Military medical officers work-
ing in regions where such infections may be ex-
pected to occur with any considerable frequency
will undoubtedly be grateful for the appearance of
this volume. It should also fill the long-felt need
for a text which can be recommended to medical
students equally when they are beginning to study
clinical mycology and later when they are about to
enter private practice.

The early chapters deal with the generalized
mycoses and those affecting the deeper tissues of
the body. The discussion of each type of infection
includes a summary of its known geographic dis-
tribution; symptomatology; verbal, photographic
and x-ray description of the gross lesions; path-
ology seen at biopsy and at autopsy; photomicro-
graphs of sections of affected tissues; differential
diagnosis with the aid of clinical signs, cultural
methods or animal inoculations; photographs of
distinctive microscopic features and characteristic
giant colonies of the etiologic fungus on artificial
medium; immunology; prognosis and treatment of
the disease.

Subsequent chapters deal with the superficial
dermatomycoses, beginning with a general discus-
sion of their symptomatology; prognosis; treat-
ment; immunology and mycology. There follows a
more detailed analysis of the important infections
in this group, utilizing a method of presentation
similar to that for the systemic mycoses. Finally
there are chapters on the fundamentals of elemen-
tary mycology and methods for the recognition of
fungus contaminants, as well as a brief but ade-
quate appendix containing a summary of useful
procedures and materials for the study and treat-
ment of the various clinical conditions.

Each of the authors has contributed a discussion
of those particular aspects of the various infec-
tions in which he is expert and the material has
been presented with a uniformity which contributes
greatly to the excellence of the book as a whole.
The publishers have also done a splendid job in
reproducing the abundant photographic material
and in setting up the volume so that it can be

432

Book Reviews

handled conveniently. One of the few ways in
which this manual might be further improved
would be the substitution of colored plates for
black and white illustrations in reproducing the
features of the lesions and cultural characteristics
of the fungi. This however would undoubtedly add
considerably to the expense of the book and we can
be very grateful for the high quality and reason-
able price of the volume as now published.

Morris F. Shaffer, Ph. D.

Etiology, Diagnosis and Treatment of Amebiasis:

By Charles Franklin Craig, M. D., M. A. (Hon.),

F. A. C. S., F. A. C. P. Baltimore, The Wil-
liams & Wilkins Company, 1944. pp. 332. Price,

$4.50.

This volume is substantially a revision of the
author’s work entitled “Amebiasis, and Amebic
Dysentery” , which was published in 1934. The
volume consists of twelve chapters under the fol-
lowing headings: Introduction; The Etiology of

Amebiasis and Amebic Dysentery; The Epidemi-
ology of Amebiasis; The Pathology of Amebiasis;
The Pathology of Amebiasis (Continued); The
Symptomatology of Amebiasis; The Complications
and Sequelae of Amebiasis; Clinical Diagnosis of
Amebiasis: Microscopical and Cultural; Laboratory
Diagnosis of Amebiasis: Serological; The Prognosis
and Prophylaxis of Amebiasis; The Treatment of
Amebiasis.

The author brings to bear on the subject a rich
experience and sound judgment that leave no
ground for criticism and little for comment. At
the end of the volume is a very complete list of ref-
erences and an author’s index. A modest number
of well chosen illustrations serve to illustrate spe-
cial features. Among the many points of special
interest to the reviewer is the emphasis laid on the
possibility of missing the Endamocba histolytica in
a single examination. The author lays special em-
phasis on the importance of adequately-trained
laboratory personnel if the results of the laboratory
examinations are to have any value. Col. Craig
believes that there is a difference in virulence
among the strains of the organism and that those
in the tropics are more virulent than are those
found in temperate climates. In agreement with
the views of most men who have had experience
with the amebiasis among military personnel,
flies are regarded as important transmitting
agents. The author considers that the importance
of lower animals as sources of infection may be
worth further investigation. He is clearly of the
opinion that a tropical climate induces lower resist-
ance of the human carrier. It is gratifying to find
stress laid on the importance of considering ame-
biasis when a diagnosis of appendicitis is being
weighed, a feature often overlooked by clinicians.
On the important subject of food handlers as pos-
sible sources of infection, while the author regards
examination and elimination of carriers as import-

ant, he considers this can well be carried out only
in special groups. He regards “routine examina-
tion of all food handlers and their proper treat-
ment as an ideal impossible of attaining and eco-
nomically most costly.”

One is pleased to find so distinguished an au-
thority advising against surgical procedures, ap-
pendieostomy and cecostomy as inadvisable. The
final paragraph of the book is a plea for better un-
derstanding and practice from the point of view of
public health, a very fitting conclusion for so im-
portant and authoritative a work.

G. W. McCoy, M. D.

PUBLICATIONS RECEIVED

Lea & Febiger, Philadelphia: Internal Medicine,
Its Theory and Practice, Edited by John PI.
Musser, B. S., M. D., F. A. C. P.

D. Appleton-Century Company, New York and
London: Approved Laboratory Technic, by John

A. Kolmer, M. S., M. D., Dr. P. H., Sc.D.. LL.B.,

L. H. D., F. A. C. P.

The Williams & Wilkins Company, Baltimore:
The Abortion Problem, Proceedings of the Confer-
ence Held Under the Auspices of the National
Committee on Maternal Health, Inc.

Paul B. Hoeber, Inc., New York and London:
Anatomy As a Basis for Medical and Dental Prac-
tice, by Donald Mainland, M. B., Ch. B., D. Sc.,
F. R. S. E„ F. R. S. C.

The Commonwealth Fund, New York: American
Medical Practice in the Perspectives of a Century,
by Bernhard J. Stern, Ph. D. Patients Have Fami-
lies, by Henry B. Richardson, M. D., F. A. C. P.

The Philosophical Library of New York, New
York: Modern Methods of Amputation, by Ed-

mundo Vasconcelos, with an Introductory Survey
of The Development of Amputation by Major Gen-
eral Norman T. Kirk, M. C.

The Jaques Cattell Press, Lancaster, Pa.: The

Marihuana Problem in the City of New York, by
the Mayor’s Committee on Marihuana.

Chemical Publishing Company, Inc., Brooklyn,
N. Y. : The Chemistry and Pharmacy of Vege-

table Drugs, by Noel L. Allport, F. I. C.

Charles C. Thomas, Springfield, Illinois: Poet

Physicians, An Anthology of Medical Poetry Writ-
ten by Physicians, compiled by Mary Lou Mc-
Donough.

University of Michigan, Ann Arbor, Michigan:
Technique of the Standard Kahn Test and of Spe-
cial Kahn Procedures, by Reuben L. Kahn.

College Book Company, Columbus, Ohio: A

Test for Color Blindness, by P. B. Wiltberger,

M. D.

New Orleans Medical

and

Surgical Journal

Vol. 97 APRIL, 1945 No. 10

IN MEMORIAM

DOCTOR STANFORD E. CHAILLE

THOMAS S. KAVANAGH, M. D.

New Orleans

Once again we are assembled fittingly to
make manifest our enduring reverence for
the memory of one of the greatest men of
medicine of our time, Stanford Emerson
Chaille — the mere mention of whose name
evokes in all of us the tenderest of emotions
and impels us pause to contemplate in ad-
miration and with deep respect a life so glo-
riously well spent, while out of the depths
of our memories, well-up pleasing reflec-
tions of those many happy moments in our
own lives, made blessed by their contacts
with his.

That our distinguished President, Dr.
Edwin L. Zander, should assign me to speak
for a few moments here upon Dr. Chaille’s
life and my personal relations with him as
a small contribution to this memorial, is to
have conferred upon me an honor far be-
yond my meager ability, or my merit; and
it is therefore with temerity that I approach
the task. However, since it is, I am sure,
in no sense expected of me to add by my
poor oratory even a scintilla to the lustre of
Dr. Chaille’s fame, I do believe I may be
privileged at least to epitomize a few of the
high-lights in his marvelous career, for the
benefit of those of us who have but recently
become affiliated with our Society and in
consequence are little acquainted with his
life, filled as it was with so many magnifi-

*Nineteenth Annual Stanford E. Chaille Ora-
tion, delivered on November 6. 1944, before the
Orleans Parish Medical Society.

cent achievements, as a result of which his
country, his fellowmen and medicine are so
justly proud of him.

After graduating from the medical de-
partment of the University of Louisiana,
now Tulane, his studies took him abroad,
where in Paris he studied physiology un-
der the great Claude Bernard. In 1859 he
was demonstrator of anatomy here. In the
early days of the War Between the States,
he was acting Surgeon General of Louisiana
after which he was the Medical Inspector of
General Bragg’s army in Tennessee, then
later he was in charge of a hospital in At-
lanta, from which place he was ordered to
Macon, there again heading a hospital. He
was taken prisoner at Macon, and after the
cessation of hostilities resumed his activities
in this city. A paper of his on Medical Ju-
risprudence, written by request, when read
at the International Medical Congress in
Philadelphia, immediately prompted over-
whelming and well merited praise from
both the President and Congress of the
United States. He served as Secretary of a
board of twelve appointed by Congress to
investigate yellow fever and its cause. He
was chairman of the group of four consti-
tuting the Havana Yellow Fever Commis-
sion appointed by the National Eoard of
Health, later becoming a member of the Na-
tional Board of Health appointed by Presi-
dent Arthur, being also its Inspector Gen-
eral in New Orleans. He was the moving
spirit behind the enactment of Medical Laws
in Louisiana. He was one of the founders
and charter members of this Society. He
succeeded Dr. Richardson as Dean of the
Medical Department of Tulane University,
in which capacity he served for almost a

434

Xavanagh — In Memoriam

quarter of a century, passing to his eternal
reward, May 27, 1911. It was not his mere
participation in these events just recounted
that made Dr. Chaille the great man that
he was, but rather his unremitting zeal,
deep comprehension of purpose and his in-
defatigable devotion to the duties involved,
toward each of which his great energies
were bent with firmness and the full con-
viction that in the end his every high hope
and noble resolve would merit the crown of
success.

During my attendance at Tulane Medical
School he was Dean and also filled the Chairs
of Pathology, Physiology and Hygiene. My
personal relations with Dr. Chaille were al-
ways most agreeable and pleasant, and nu-
merous enough, even at this late hour, to
permit me. without the exercise of my imag-
ination to recall quite vividly his colorful
and commanding personality, as well as the
impressions that he made upon me and I
might also say upon my fellow students. In
the early periods of my attendance at his
classes all of my fellow students and I looked
upon him in great awe, not because he was
in any way austere or distant in his man-
ner towards us, but rather because we
seemed to sense in him a living encyclo-
pedia of all medical lore. But we soon be-
gan to recognize his masterful knowledge of
the subject matter of his lectures, his un-
equalled pedagogic technics and his pro-
found psychologic procedures, which at all
times intrigued our interest and held our
undivided attention, while we sat spell-
bound in his presence.

And over and above all these, he mani-
fested toward all of us a parental interest
that was well calculated to inspire each of
us to greater effort; indeed his influence
upon us was most wholesome.

I am sure that each of my fellow students
and I will today acknowledge with profound
gratitude the profit that must of necessity
have accrued to each of us, as a result of
the application in our daily lives of the sub-
lime principles which, as our Dean, Dr.
Chaille so ardently endeavored to inculcate
in his various dictums, through many of
which by subtle suggestion he sought to

arouse our impulses to highest ideals and
kindle our intellects to greater endeavors.

I can recall with what indescribable urge
he exhorted us to the exercise of our own
initiative, that great force through which
alone all the hidden truths of medicine have
been unearthed.

You will pardon, I feel sure, my allusion
to the pride that seemed to suffuse our very
being, when he with unerring accuracy pic-
tured to us the unique and sacred relation-
ship that a physician bears to his patient,
at which moment his very spirit seemed
alight with the hope that we would never
violate it.

May I also add how shortly before our
graduation our young and eager hearts
throbbed with emotion when he in most
solemn tones invoked that ancient oath of
Hippocrates, every provision of which he
then assured us was as applicable in our
lives as it had been in the lives of those
among whom it was first ordained and ut-
tered.

I recall his abhorrence to all ironclad
dogmas, cults and isms in medicine, his
maintenance of the right of another, no mat-
ter how humble or obscure he may seem, to
hold such view as in his opinion, earnestly
held, seemed correct and true, and his firm
advocacy of the right of medical men to or-
ganize and his ardent love for our beloved
profession.

Friends, I could go on for hours recalling
to memory the many happy occasions that
graced my life in his presence, and proclaim-
ing the virtues, intellectual abilities and
mental traits of Dr. Chaille, who, as all of us
must now know, many times by his presence
and words of wisdom lent grace and dignity
to many of our gatherings, but time does
not permit. In no more fitting manner, I
am sure, may we dignify this occasion than
by the perpetuation of this our yearly cus-
tom of listening to the voice of our beloved
science, as she eloquently speaks with au-
thority through the lips of one of her illus-
trious sons, one of whom, the distinguished
Dr. Kolmer of Temple University, will
honor with us the memory of Dr. Chaille
by his presence here tonight.

Silverman and Leslie — Amebic Colitis

435

In closing may I hold up to the view of
those of us who are young in this our field
of hope, labor and service the life of Dr.
Chaille as one they should endeavor to emu-
late, remember

“The lives of great men all remind us

We too can make our lives sublime

And departing leave behind us foot-
steps on the sands of time.”

o

ATYPICAL AMEBIC COLITIS*

DANIEL N. SILVERMAN, M. D.
and

ALAN LESLIE, M. D.

New Orleans

In any presentation of atypical forms of a
common ailment, the natural expectation
would be to hear about unusual or bizarre
manifestations of the particular disease.
When amebiasis is the subject of the dis-
cussion, this expectation is not warranted.
Since amebiasis is as great a mimic of ab-
dominal disease as syphilis is of systemic
disease, and atypical forms of one sort or
another perhaps outnumber the so-called
typical cases, the common deviations from
the classical picture, as well as more un-
usual forms should be included under this
title.

What is meant by a “typical” case of
amebic colitis? Such a case would prob-
ably conform to the description given in any
standard textbook of medicine. Unfor-
tunately for diagnosis, this description fre-
quently does not hold good. From the pub-
lic health standpoint, on the other hand, this
discrepancy is perhaps an advantage, since
it has been estimated that the protozoon is
harbored by about 10 per cent of the general
population, a large segment to be disabled
by a single disease, if all had the text-book
form.

There is great variability of leading
symptoms. Although diarrhea is accepted
as the standard symptom, close to 50 per
cent of patients with proved amebiasis give
a history in which constipation is featured.
Some cases of long duration, say 10-20

*Read before the Orleans Parish Medical So-
ciety, October 9, 1944.

years, tell of diarrhea at the onset, followed
by intermittent diarrhea, but a generally
constipated condition. Mild abdominal dis-
tress with or without a history of an occa-
sional loose stool is a common symptom.
One rather recent patient, a 21 year old
girl had a chief complaint of dysmenorrhea,
with no symptom referable to the bowel.
The gynecologic approach to her problem
was fruitless, but anti-amebic therapy
brought marked amelioration. Clinically,
amebic colitis commonly simulates chronic
cholecystitis, cholelithiasis, peptic ulcer,
and pancreatitis. The full syndrome of in-
testinal obstruction can be produced by the
granulomatous form of the disease, and
laparotomy after a preoperative diagnosis
of colonic neoplasm has been a not uncom-
mon error — error, since emetine therapy
results in a dramatically rapid lysis of the
granuloma with consequent relief of the
obstruction.

Amebic colitis can be a hyper-acute dis-
ease of extreme gravity. Three cases of
this so-called ulcero-necrotic form were re-
cently described by the authors.1 The en-
tire life span of the patient, from the onset
of symptoms to death may be less than a
week. A rapidly fatal exacerbation may
occur in a long standing case. These cases
are to be differentiated from more conven-
tional forms in which severe complications
may eventuate, but are fulminating from
the onset and unaffected by specific ther-
apy. This type of case is rather rare in this
country, but has been described as occurring
in China and the Philippines by Faust,2 who
suggested that outlanders becoming infect-
ed in locales of hyperendemicity are the in-
dividuals liable to contract this serious form
of the disease.

Included in the aforementioned 10 per
cent are many individuals unaware of their
harboring the ameba. These are custom-
arily referred to as carriers, but the ac-
curacy of this designation is open to ques-
tion, since they may at any time develop
some clinical manifestation of the disease.
Some patients have no complaint more spe-
cific than lassitude, frequently of years’
duration, not knowing the experience of

Silverman and Leslie— Amebic Colitis

436

good health, which comes as a revelation
after successful anti-amebic therapy.

With increasing experience it is becom-
ing more and more apparent that there is no
truly typical case of amebiasis, that the dis-
ease is protean, widespread, and must ever
be borne in mind as a diagnostic possibility.

There is a parallelism between the vari-
ability of clinical picture and the variability
of pathology, which may or may not be re-
flected by the proctosigmoidoscopic appear-
ance of the lower bowel. What is the com-
mon conception of the pathology of amebic
colitis? Quite correctly one brings to mind
a process in which there are discrete, under-
mined, flask-shaped ulcerations with nor-
mal or nearly normal intervening mucous
membrane. The ulcer base overlies submu-
cosa, muscularis, or serosa, depending on
the depth of penetration. Cysts and tropho-
zoites of Endameba histolytica may be seen
in the necrotic centers and in the surround-
ing tissues. The cecum and rectosigmoid
are the areas of predilection of the lesions.
This might be considered the typical path-
ology, which may be complicated relatively
rarely by hepatitis and abscess of the liver
or perforation and peritonitis. Actually
great variation from this picture is com-
monplace. There may be no more than a
few areas of superficial ulceration in the
entire colon. At the other extreme there
is the ulcero-necrotic type of amebiasis, in
which there is deep, diffuse, confluent, ser-
piginous ulceration, producing a condition
of the bowel difficult to distinguish procto-
scopically from chronic ulcerative colitis in
aggravated form. In these cases sloughing
of whole sections of the bowel may be en-
countered. In one of these cases reported
by the authors the entire posterior wall of
the transverse colon sloughed out, and at
autopsy it was seen that the posterior bowel
wall was made up of matted loops of small
intestine. In another of these cases a piece
of tissue identified histologically as nonde-
script necrotic material was passed by rec-
tum. Figure 1 shows the deep undermin-
ing penetration of a necrotizing amebic ul-
cer, illustrating the process by which plough-
ing takes place. It is interesting and per-

haps important to note here that two of the
three cases of ulcero-necrotic amebic colitis
reported had a complicating infection due
to B. dysenteriae, one a Flexner and the

Fig. 1. Section through ulcer of colon showing
penetrating necrosis and numerous trophozoites
of Endameba histolytica throughout the submu-
cosa and muscularis. Lateral dissemination pre-
disposes to sloughing of superficial layers.

other a Shiga. The question arose as
to which pathogenic organism played the
dominant role, whether the amebae caused
necrosis by blocking the intestinal blood
supply, or whether the necrosis was caused
by the bacterial toxin, or whether there was
an additive or synergistic effect.

Another unusual but distinctive form of
amebic infestation of the bowel is the type
characterized by tumor formation. In some
individuals the infestation provokes a re-
sponse'characterized by the production of
granulation tissue. Depending on the rate
of growth of the tumor, acute or chronic in-
testinal obstruction is observed. The ro-
entgenographic appearance is indistinguish-
able from carcinoma. Because of the af-
finity of the protozoon for the cecal and
rectosigmoidal regions, these are the pre-
dominant sites of amebic granulomata.
There are many reports of cases of amebic
granuloma explored in quest of a neoplasm.
Nino:! reported a case of a patient so diag-
nosed preoperatively who, following resec-
tion of the cecum and ascending colon, died
of peritonitis. At autopsy the pathology
was established as “ulcero-necrotic intesti-
nal amebiasis with amebic tumor of the
cecum and ascending colon.” The authors

Silverman and Leslie — Amebic Colitis

437

observed amebic granulomata in a husband
and wife. The wife underwent a resection
of the cecum for what purported to be a
neoplasm (fig. 2) the true nature of the dis-
ease being revealed only after pathologic
examination of the tissue. The husband

Fig. 2. Barium enema demonstrating cecal
filling- defect.

more fortunately presented his granuloma
within reach of the sigmoidoscope; and the
diagnosis was made by biopsy. Histologic
study of tumors of amebic etiology reveals
the presence of the organism, usually in
great numbers throughout the granuloma.

It might be charged that this has been
no more than a brief broad discussion of
amebiasis, without emphasis on the atypical.
If atypical is made synonymous with un-
usual, the authors must plead guilty. If,
however, it has been demonstrated or only
suggested that the atypical is truly the
usual in amebiasis, that amebiasis is a dis-
ease of protean nature, and a diagnostic pit-
fall, the purpose of this presentation will
have been achieved. The fact to be empha-
sized is that because of its manifold symp-
tomatology, amebiasis should always be con-
sidered in differential diagnosis.

REFERENCES

1. Silverman. L>. N., and Leslie. A. : Intractable amebic
coliiis. with special reference to the ulcero-necrotic forms,
J. A. M. A. In Press.

2. Faust. E. C. : Some modern concepts of amebiasis,
Trans, and Studies of College of Physicians of Philadel-
phia, 4 Ser., Yol. II. No. 3, December 1943.

3. Nino. F. L. : Amebiasis intestinal ulcero-necrotica y
tumor del ciego y colon ascendente, Novena reunion, Ssc.
argent, de pat. reg : 2:813, 1937.

DISCUSSION

Dr. E. Carroll Faust: The surface of a pri-
mary lesion shows a round, somewhat reddened
elevation with a pinpoint center. This is the actual
site of entry for the ameba as it digests its way
into the intestinal wall. If one wishes to visualize
where the amebic lesions are most frequent in an
average individual, he will discover that they
preponderate at the levels of primary location.
However, in the large bowel there is always the
opportunity for the progeny from the original
colonies to establish secondary lesions. The cysts
which are found in formed stools cannot penetrate
the tissues until they have excysted and the stage
found in the tissues is always the active vege-
tative one.

A diagrammatic representation of the number of
lesions in an average individual at different levels
of the bowel indicates that in the cecal area (that
is, the cecum, appendix and adjacent portion of
the ascending colon), there is on the whole the
largest number of lesions, while in the sigmoido-
rectal area, which can be visualized with the proc-
toscope, there is the second largest number. There
are usually relatively few lesions in the inter-
mediate parts of the colon, even at the flexures,
compared with the heavily infected site at both
ends of the large bowel. Undoubtedly the largest
number of individuals have primary lesions in the
cecal area, but later, as the progeny pass down
and produce colonies at lower levels, the colon and
rectum become increasingly involved. This ex-
plains why such a large number of these chronic
cases of amebic colitis have ulcerating lesions, ci-
catrices and amebomas in the proctodeal level which
can be visualized by sigmoidoscopy.

Dr. Gordon McHardy (New Orleans) : After
listening to the excellent presentation by Dr. Sil-
verman and Dr. Leslie and the instructive discus-
sion by Dr. Faust, it seems almost impossible for
anyone to add further to the subject. However,
there is one point I feel Dr. Faust dislikes which
came into interest recently with us and I would
like, if possible both Drs. Silverman and Leslie
and Dr. Faust to add discussion on this one atypi-
cal point we have found occurs in amebiasis. It
is commonly believed that fever is not a part of
uncomplicated amebiasis; however in 790 cases
reviewed last year 52 cases, uncomplicated as far
as it was possible to determine, showed fever. Of
these 52 cases there were acute amebic dysentery
manifestation in twelve; chronic dysenteric symp-

438

Watt — Acute Diarrheal Disorders

toms in 32, and so-called carrier state in the re-
mainder. I think the febrile issue is of interest
when one considers atypical amebiasis. The fact
that fever has a relation to amebiasis, is demon-
strated by the fact that these patients become
afebrile after satisfactory therapy.

The essayists have presented an excellent paper
which brings attention to the fact that amebiasis
has serious complications which everyone should
consider. If right in the assumption, I think only
six cases in our series were similar to those pre-
sented tonight. Two of these, I know were Dr.
Silverman’s cases. Of the six, two were operated
on and both recovered. Certainly it would have
been disastrous if either had died, after having
had a major abdominal procedure, from an illness
correctable by medical measures. With an inci-
dence of amebiasis in 16 per cent of examined
patients in our study, the overwhelming impor-
tance of an abdominal search for amebiasis in all
abdominal cases is imperative.

Dr. D. C. Browne (New Orleans) : Dr. Silverman
and Dr. Leslie have called attention to a clinical
occurrence we will probably see more frequently.
An infection involving 10 to 16 per cent of our
population is entitled to more consideration than
now given by the thinking physician. Certainly,
an infection capable of producing these complica-
tions, mortality and morbidity, should be treated
more thoroughly and carefully, for it is not at all
improbable that such amebic granulomas as pre-
sented here are the result of inadequate treat-
ment. I am convinced that the ease with which
symptoms may be relieved with the present excel-
lent therapy has promoted negligence.

It must be borne in mind that only a small per-
centage of gastrointestinal symptoms the amebia-
sis case presents are the direct result of the infec-
tion; less than 39 per cent may be related and
the findings of Endameba histolytica in no sense
relieves the clinician of his responsibility in mak-
ing a careful gastrointestinal study. Evaluation
necessitates careful clinical judgment.

Dr. J. A. Colclough (New Orleans) : It is ele-
mentary to say one can have amebic abscess with-
out amebic dysentery. I quite agree with the es-
sayists that amebiasis is the great imitator of the
abdomen. It was my good fortune to read, during
the past few months, something of the use of
thorotrast in the diagnosis of liver conditions.
I removed a gallbladder in a young woman in
March, which was full of stones. She made an
uneventful recovery and became febrile four weeks
after operation. Temperature was septic and an
internist and I disagreed between the presence of
subphrenic abscess and liver abscess. Repeated
examinations of stools were negative for amebae.
We injected thorotrast intravenously. Two hours
later a picture of the liver and spleen showed, with
diagrammatic clarity, a circulai area of lessened
density of the liver. Aspiration revealed presence

of liver abscesses, which had been suspected and
could not be proved. I would like to recommend
use of thorotrast in diagnosis of atypical ame-
biasis and obscure abdominal conditions.

Dr. D. N. Silverman (In closing) : I wish to
thank Drs. Faust, McHardy, Browne and Col-
clough for their discussion of this paper. I believe
that our demonstration provides clinical and path-
ologic corroboration of Dr. Faust’s outstanding
experimental work on the sites of amebic invasion
of the colon. The most acute case of ulcero-necro-
sis of the colon in our experience was a massive
slough of the entire transverse colon. The man
died two days after onset. This man was also
infected with the dysentery bacillus. That brings
up the question whether or not many of these ful-
minating cases with severe symptomatology and
early death are complicated by previous or con-
comitant infection of the individual by the dysen-
tery bacillus.

In answer to Dr. McHardy: In a survey of a
large series of cases there must be considered the
complications of chronic amebic colitis. We know
now that hepatitis is quite frequent without local-
ized abscess formation and can be the cause of
fever. I do agree that some of our own patients
have had fever, even before a complication was
demonstrated.

Dr. Browne mentioned adequate therapy of ame-
biasis. I am disheartened over the attempts at
adequate therapy as employed today, since many
of our cases of chronic, long-standing amebic co-
litis refuse to respond to all the known drugs now
used in anti-amebic therapy.

0

THE DIAGNOSIS AND TREATMENT OF
ACUTE DIARRHEAL DISORDERS*

JAMES WATT, SURGEON, USPHSt
New Orleans

Physicians in the active practice of medi-
cine have given little attention to the etio-
logic diagnosis of the acute diarrheal dis-
orders. This group of diseases can not be
diagnosed with accuracy clinically, and the
necessary laboratory procedures were in
the past complicated and to a great extent
unsatisfactory. A further deterrent was
the fact that specific therapeutic measures
were not available, and thus there w7as no
practical importance to the diagnosis of a

::Read before the Orleans Parish Medical So-
ciety, October 9, 1944.

fFrom the Division of Infectious Diseases, Na-
tional Institute of Health, Bethesda, Maryland,
and the Charity Hospital of Louisiana at New
Orleans.

Watt — Acute Diarrheal Disorders

439

single case on etiologic rather than symp-
tomatic grounds. Recent progress in lab-
oratory technic has now given us a simple
but effective diagnostic test, and studies on
the effectiveness of sulfonamide prepara-
tions in various intestinal infections have
clearly shown that an etiologic diagnosis is
essential if the patient is to receive the best
type of medical care.

ETIOLOGY

To begin with, it has been found that the
great majority of all acute diarrheal disor-
ders which come to the attention of the phy-
sician in this country are infectious in na-
ture and are caused by a member of either
the Shigella or the Salmonella group of or-
ganisms.

The importance of these two groups as a
cause of acute diarrhea is shown in the two
charts which follow. The first (chart 1)

results in New Mexico, Georgia, Puerto Rico
and Shreveport stand in marked contrast to
those obtained in the New Orleans Charity
Hospial. Salmonella infections, which were

ACUTE DIARRHEA IN THE GEN. POPULATION
AND IN VARIOUS HOSPITAL SERIES
O 10 10 30 +0 SO 60 70 SO 90 100

NEW MEXICO
AND GEORGIA
GEN. POPULATION

76 Vo

LESS THAN 1 %

PUERTO RICO | 76 %

HOSPITAL | LESS THAN 1%

SHIGELLA

SALMONELLA

SHIGELLA

SALMONELLA

SHREVEPORT, LA. | 75% ~|

HOSPITAL | NONE

NEW ORLEANS, LA. [~ 47% I
HOSPITAL | 25 % I

TOTAL POSITIVE IN
NEW ORLEANS - 72. %

SHIGELLA

SALMONELLA

SHIGELLA

SALMONELLA

Chart II. The percentages of acute diarrheal
disorders culturally positive for Shigella and Sal-
monella in selected general population studies and
in hospitalized cases in different georgraphical

areas.

PROPORTION OF CASES OF ACUTE DIARRHEA
CULTURALLY POSITIVE FOR SHI6ELLAE

InvMtigJtor Yejr PtrcMt of Cmi Positive

Chart I. The proportion of acute diarrhea found
positive for Shigella by different investigators
since 1900 in different areas of the United States.

gives the diagnostic results obtained by va-
rious workers in this country since 1900.
The relatively slight variation in findings,
in spite of different laboratory technics, is
striking.

Of more interest to Louisiana physicians
are the results shown in chart 2. These are
selected portions of our own studies. In it
are given the laboratory results of fecal cul-
tures obtained from cases of acute diarrhea
in several geographic areas. Except in the
New Mexico-Georgia series these are hos-
pital and outpatient cases, in other words,
patients sufficiently ill to seek medical care
on their own initiative. The uniformity of

an unimportant fraction of the total cases
seen in most areas, make up at least 25 per
cent of the cases studied in New Orleans up
to this time.

SULFONAMIDE THERAPY

The practical importance of these obser-
vations lies in the therapeutic response of
these different organisms to sulfonamide
therapy.

The results of recent studies may be sum-
marized as follows : For Shigella infections
there are effective specific therapeutic
measures although there are important dif-
ferences in the response of different va-
rieties to the drugs employed. Against the
Salmonella infections we do not have such
effective agents.

Sulfonamide therapy in shigellosis got
its first big impetus from the development
and application of sulfaguanidine in the
treatment of intestinal infections. Its use
has been widespread and many other pre-
parations have also been utilized. In the
study, the findings of which are partially
summarized on the following charts, two
criteria of effectiveness were employed ;
first, the clinical response of the individual
to treatment, and second, the results of daily
fecal cultures with colony counts of patho-

440

Watt — Acute Diarrheal Disorders

genic organisms. The latter procedure is
a far more accurate index of the effective-
ness of a drug. It is a truly objective
measure and not subject to individual inter-
pretation, and it is therefore the one relied
on primarily at the present time.

One point a little aside from the main
question of therapeutic effectiveness is of
interest. There has been considerable dis-
cussion on the merits of readily absorbed
versus poorly absorbed sulfonamides in the
treatment of enteric tract infections. Chart
3 shows the level of dissolved sulfonamide

SULFONAMIDE LEVELS IN CENTRIFUGED
AND WHOLE FECAL SPECIMENS
DISSOLVED AND TOTAL SULFONAMIDE COMPARED

SULFONAMIDE

DIAZINE

MERAZINE

GUANIDINE

Dally

dose

Mgm per 100 cc. Feces
0 10 20 30 40 50 60 70 60 SO

i i i 1 1 1 1 — — i 1

♦ Scale in hundreds of mgm's per 100 cc.

Range of Levels in Centrifuged Fecal Specimen

Range of Levels in Whole Fecal Specimen

| Average Sulfonamide Levels

Chart III. Sulfonamide levels found in fecal
specimens showing range of levels in centrifuged
(dissolved therapeutically active portion) and in
whole (total sulfonamide) specimens.

THE RELATIVE EFFICACY OF SULFONAMIDES
IN SHIGELLA ( FLEXNER ) INFECTIONS

compared with the total sulfonamide levels
in feces. It is important to note that the
absorbed compounds such as sulfadiazine
are present in the stool and that the level of
dissolved drug, the therapeutically active
portion, is higher than that sought in the
blood for treatment of parenteral infections.
The absorbed compounds are therefore able
to attack both the organisms in the lumen
of the bowel but also those more intimately
associated with the mucosa and glands.

The observation makes much less sur-
prising the data in chart 4, which show the
therapeutic results in seven groups of cases
of Shigella parody senteriae Flexner infec-
tions treated with seven different sulfona-
mide preparations, as compared with the re-
sults in an untreated group of similar cases.
All the sulfonamides tested were of definite
value in eliminating the organisms from the
intestinal tract. The most effective among
those tested was sulfadiazine and least ef-
fective was sulfaguanidine. In this par-
ticular group all individuals treated with
sulfadiazine had negative stool cultures by
the end of the third day of treatment ; 95
per cent of the controls were still positive at
the end of the same period of time. The
other preparations used, sulfapyrazine, sul-
famerazine, sulfamethazine, sulfathiazole
and sulfasuxidine, were in general effective
in the order named with little variation be-
tween them.

Percent of Cases with Persisting Positive Cultures

THIAZOLE

PYRAZINE

P

MERAZINE

METHAZINE GUANIDINE

SUXIDINE

□ = 20 percent of cases with persisting positive cultures

Chart IV. The efficacy of seven different sul-
fonamide preparations in the treatment of Shigella
paradgsenteriae Flexner infections as indicated by
the percentage of continuing positive cultures.

In chart 5 is compared the response to
sulfadiazine in epidemics due to three dif-
ferent members of the Shigella group. The
curves which, represent the reduction in the
number of organisms found in stool cul-
tures and the reduction in the total number
of positive individuals found by daily stool
cultures are roughly similar for each given
organism. It should be noted, however,
that the average colony count declines more
rapidly than does the total number of de-
tected infected individuals. These graphs
are representative of a much larger series
of outbreaks studied. From our experience
in these studies we now know Flexner infec-
tions clear up rapidly and usually com-
pletely ; Schmitz infections respond only a
little less favorably; and that a Sonne infec-

Watt — Acute Diarrheal Disorders

441

TH£ SESPOHSE Of DIFFERENT VARIETIES OF SHIGELLA E TO
SULFADIAZINE

Aocrafa count

SOMME

_r

□ = 20 percent of cai«s with persisting positive

cultj

Chart V. The response to sulfadiazine therapy
of different varieties of Shigella in observed out-
breaks as indicated by the percentage of continu-
ing positive cultures and the average plate colony
count given by these cultures.

tion is much more likely to be resistant to
therapy.

Epidemics of course are special occur-
rences and do not necessarily reflect the con-
ditions found in endemic infections. A
study now in progress of endemic cases
shows that the results first cited are sub-
stantially those which may be expected in
general practice. To date in this series only
1 per cent of the Flexner infections have
been resistant to sulfonamide therapy. On
the other hand, approximately 12 per cent
of the cases due to S. sonnei have failed to
respond to the various sulfonamides used.
Most of these resistant patients recovered
symptomatically in a short time, and fre-
quently there was a marked reduction in
the number of organisms found in the stool
culture, which reduced their hazard as
sources of infection for others.

Of further practical importance is the
size of the dose of sulfonamide which has
been found effective. An outbreak of Flex-
ner infections was abruptly terminated by
single doses of 2 grams of sulfadiazine given
at the same time to all infected and exposed
individuals. The optimum dose has not yet
been definitely ■ determined, but for Flex-
ner infections it is probably not over 2

grams per day for four days. Such small
doses, however, are not only ineffectual in
the treatment of Sonne infections but ac-
tually promote the development of sulfona-
mide resistant strains. This has been ob-
served both in vivo and in vitro.

Cases of acute diarrhea due to Salmonella
infection are apparently not benefited by
sulfonamide therapy. Due to the large num-
ber of types found in this group, this state-
ment must be tentative until a greater num-
ber of observations can be made. This
much, however, can be said with certainty :
No member of this group who has been ob-
served with sufficient frequency to permit
controlled observations has been signifi-
cantly affected by sulfonamide therapy.

DIAGNOSIS

It is obvious from these findings that if a
patient is to receive the full benefit of pres-
ent day knowledge, therapy of the diarrheal
disorders must be controlled by stool cul-
tures. To do this easily and accurately re-
quires no more training than is involved
in routine blood and urine studies if full ad-
vantage is taken of the methods now avail-
able. The basic procedure would be the
same under all circumstances, but the imme-
diate location of laboratory facilities, the
type of practice and other conditions call
for modifications to fit the practical situa-
tion.

Basically the procedure is as follows : The
physician or his nurse helper takes a culture
by rectal swab when the patient is first
seen, plates it directly to SS agar, and sends
the inoculated plate to the laboratory for in-
cubation and identification of such patho-
gens as may be present. Laboratory meth-
ods are available which permit reliable
identification within 36 hours after the
plate has been received. This is entirely
feasible whenever laboratory facilities,
either private or public, are available in the
same town.

Several modifications of this method have
been tried out successfully. In the New
Orleans Charity Hospital prepared plates
of SS agar are kept in the Central Service
of wards which have an active admission
rate of diarrheal disease. The interne

442

Watt— Acute Diarrheal Disorders

takes the culture when he examines the pa-
tient and sends the labeled plate back to the
Central Service. From there it goes to the
laboratory.

It is entirely feasible for physicians to
keep the plates in their office, plate the cul-
tures as described, and send the plates to
the laboratory at the end of the day. That
this method is valuable to the clinician is
shown by these facts : On the average, re-
ports to the hospital physician are given
verbally within 36 hours after admission
when swab specimens are taken. When a
stool culture is ordered on the chart, to be
taken in the usual routine manner, the aver-
age time from admission to verbal report is
between six and seven days.

When laboratory facilities are not readily
available a slightly more difficult but rela-
tively simple procedure may be used. The
culture media are all available in dehydrated
form. The medium can be prepared in a
few minutes, since it is only necessary to
add distilled water, bring the mixture to a
boil, and pour it into the plates. They may
be inoculated as soon as the agar has solidi-
fied. The plates are kept for 18-20 hours in
an incubator and then examined. Room
temperature can be used but it is not recom-
mended, since growth is slower and colony
differentiation less satisfactory. Suspicious
colonies, which on SS agar are colorless or
white, are then fished to a triple sugar iron
agar slant. The reaction produced by
growth on these slants permits a prelimi-
nary identification which, while admittedly
incomplete, gives a very good differentia-
tion of the cases into three groups, those due
to Shigellae, those due to Scilmonellae and
those from which no pathogen is isolated.
Such cultures are easily mailable to a cen-
tral laboratory for complete identification.

In the event that none of these procedures
is feasible, there is another possibility. As
we have seen, the type of infection in a
given area is not necessarily the same as in
another area of the same state. However,
through the cooperation of the physician
with local health authorities, surveys may
be conducted which will show the prevail-

ing type in specific localities and thus per-
mit a more rational therapy.

MANAGEMENT OF CASES

What then, is the method of choice in the
management of the acute diarrheas today?
No single treatment schedule can be laid
down as optimum. The known facts should
be adapted to the particular conditions and
type of practice of the individual physicians.

Since Shigella infections predominate in
most areas in this country the following pro-
cedure is recommended for hospitalized
cases. After taking a culture on admission,
sulfadiazine should be started in a dosage of
4 grams per day for adults and proportion-
ately smaller amounts for children. This
dosage should be continued if Sonne infec-
tion is found, but half this amount is suffi-
cient for Flexner infections. The sulfona-
mide should be discontinued if Salmonella
or negative findings are reported. Cultures
are then taken on the second or third hos-
pital day and thereafter daily until two con-
secutive negatives have been obtained. The
drug may then be discontinued even though
symptoms have not entirely disappeared
since a longer time may be required for
epithelialization of the extensive ulceration
of severe cases than is needed for bacteri-
ologic cure. In New Orleans and other
areas in which a high proportion of the
cases are due to Salmonella infection, it
seems better, except in critically ill patients,
to wait until an etiologic diagnosis has been
made before beginning specific therapy.

In office or home practice, even though
an admission culture is feasible, repeated
cultures to determine when therapy may be
discontinued are usually impractical. A
convenient rule of thumb is to treat Flexner
infections for five days and Sonne infec-
tions seven to eight days.

When no laboratory control is possible, a
therapeutic trial with a sulfonamide drug
is certainly indicated in all severe cases of
acute diarrhea. Treatment should be con-
tinued for two days after symptoms have
subsided or for a maximum of eight days.
The latter limit is set because in our experi-
ence infections which are not eradicated by
this time have not been benefited by addi-

Watt — Acute Diarrheal Disorders

443

tional treatment with sulfonamides. Fur-
thermore, when symptoms persist for this
length of time without definite improve-
ment, it is quite probable that some etiologic
agent other than Shigella is responsible for
the trouble. Two patients with a bloody
diarrhea seen within the past year are il-
lustrative. Both were proved to have Shi-
gella infections on admission, both were
treated and cleared up bacteriologically, but
symptomatically both showed little improve-
ment. In each case, trophozoites of Enda-
moeba histolytica were also found and ame-
bicidal therapy was then effectively used.
Apropos of these cases, when treatment is
attempted without adequate laboratory con-
trol it is well to remember that the great
majority of Shigella and Salmonella infec-
tions present a self-limited clinical picture,
and the longer the illness has persisted be-
fore the patient comes to the physician, the
more likely it is that other etiologic agents
are responsible.

SUMMARY

It has been shown that the acute diarrheal
diseases seen by the physician are usually
due to either the Shigella or the Salmonella
group of bacteria. These infections cannot
be differentiated clinically from each other
or from those due to other agents which
can produce similar symptoms. Such a dif-
ferentiation is of practical importance since
sulfonamide therapy is highly effective in
shigellosis but is valueless at present in sal-
monellosis. Since all sulfonamides are po-
tentially dangerous, their use should be re-
stricted to cases with positive indications
and they should be given in as small a dos-
age as is compatible with optimum thera-
peutic results. Simple but effective bac-
teriologic controls of therapy are available
and await only the interest of the practic-
ing physician before they are put into much
greater use.

BIBLIOGRAPHY

Cooper, Merlin L., Furculow. M. L.. Mitchell, A. Graeme,
and 'Cullen, Glenn B. : The relation of dysentery to the
acute diarrhea of infants and children, J. Pediat., 15 :172,
1939.

Davidson. W. C. : Bacillary dysentery in children, Johns
Hopkins Hosp. Bull., 31 :255, 1920,

Flexner, Simon, and Holt, L. Emmett : Editor’s Bacter-
iological and Clinical Studies of the diarrheal diseases of

infancy with reference to B. dysenteriae. The Rockefel-
ler Institute of Medical Research.

McGinnis, G. Foard, McLean, A. L., Spindle, F„ and
Mascy, Iv. F. : A study of diarrhea and dysentery in
Henrico Co. Virginia, Am. J. Hyg., 24 :552, 1936.

TenRroeck, C., and Norbury, F. G. : B. dysenterae as a
cause of infectious diarrhea in infants, Boston M. & S. J.,
174 :7S5, 1916.

Hardy, A. V., and Watt, James : Studies of the acute
diarrheal diseases XII. Etiology, Pub. Health Reports,
60 : No. 3, Jan. 19, 1945.

DISCUSSION

Dr. Joseph S. D’Antoni (New Orleans) : Be-

cause of the extreme importance of the diarrheal
diseases in both public health and general prac-
tice, I want to begin by saying that physicians in
Louisiana, and particularly in New Orleans, are
fortunate to have had Dr. Watt working among
them for the past two years. During this time he
has laid the groundwork for the accurate diagno-
sis and intelligent management of these condi-
tions. Certain points he had made in the course
of his presentation tonight are well worth stress-
ing again:

1. The great majority of all cases of acute
diarrhea never reach the physician but are man-
aged by home measures or on the advice of the
druggist. Patients with acute diarrhea who con-
sult a physician are usually seriously ill.

2. Bismuth and paregoric are sometimes use-
ful in controlling symptoms in diarrheal diseases,
but they do not attack the basic pathology. Etio-
logic diagnosis should be the first step in every
case, and therapy should be derived from the diag-
nostic results.

3. If diarrhea proves to be of Shigella origin,
therapy need no longer be empiric, for sulfadiazine
has been proved to be of value in these circum-
stances. This fact is of particular importance in
pediatric practice because Shigella diarrheas in
very young children are associated with a high
fatality.

4. Sulfadiazine, however, is not the solution in
all diarrheas, nor is its routine administration the
solution even in Shigella diarrheas. It is not the
solution in Salmonella infections, the incidence of
which in the New Orleans Charity Hospital, as
Dr. Watt has shown, is approximately 25 per cent.
Nor is it the solution in amebiasis, which is likely
to be the cause of acute diarrheal manifestations
in a large proportion of adults. Finally, since all
Shigella diarrheas are not due to the same strain,
the dosage of the drug and the duration of treat-
ment depend upon the particular strain present
in a particular case. Flexner infections usually
respond rapidly to sulfonamide therapy, but Sonne
infections are frequently resistant and treatment
must be carried out over a longer period of time.

In other words, without an etiologic diagnosis,
the empiric administration of sulfadiazine in acute
diarrhea may mean that a patient is being treated
uselessly because he has a Salmonella infection -r

444

Watt — Acute Diarrheal Disorders

or that he is being treated for a bacteria] disease
when actually he has a protozoal infection due to
E. histolytica; or that he is not being treated
long enough because he has a resistant Sonne
shigellosis instead of a responsive Flexner shigel-
losis.

The method of cultural diagnosis which Dr.
Watt has outlined is a simple, inexpensive and
accurate procedure, and therefore very useful in
general practice. On the other hand, I think
there is general agreement that the greater the
number of examinations, the higher is the per-
centage of positive diagnoses. For that reason,
in my own practice I employ the following more
elaborate method :

When I am consulted by a patient with acute
diarrhea I request that he collect a specimen of
the next stool. He next takes an enema consisting
of a quart of physiologic salt solution, and col-
lects a specimen of the evacuated fluid. Finally,
he is sigmoidoscoped, at the office or at his home,
depending upon the severity of his illness, the
bowel is inspected, and material for examination
is aspirated directly from the intestinal mucosa.
All three specimens are examined for E. histolytica
and other pathogenic protozoa, and the enema
specimen and the material aspirated from the
bowel wall are cultured.

The advantages of this method are threefold:
(1) All specimens examined are freshly passed
or collected, which, incidentally, is one of the ad-
vantages of the Hardy-Watt swab method; (2)
by inspection of the mucosa it is possible to dem-
onstrate the presence and degree of ulceration and
edema, and thus to grade the disease as to severity.
The information is less useful when the patient
is an infant, but in general it is valuable from
the standpoint of prognosis and indicates the
course which the disease is likely to follow. (3) A
protozoal infection coexisting with the bacterial
infection is not overlooked because it is specially
looked for.

After the diagnosis is made, my own method
of therapy in shigellosis is identical with that out-
lined by Dr. Watt, whom I should like to con-
gratulate again for his very excellent work.

Dr. D. N. Silverman (New Orleans) : If the

acute cases are going to be adequately treated, we
who have dealt for many years with chronic bacil-
lary dysentery will have to go out of business.

However, in the course of events during the past
year we have seen more cases of chronic dysentery
due to bacillus paratyphosus B, than ever before.
Dr. Watt’s paper deals only with acute bacillary
dysentery, but since chronic bacillary dysentery so
commonly follows acute shigellosis, it should be
mentioned here. If we do not see these cases in
the acute stage, giving adequate treatment, we
are going to see many of them as cases of chronic
dysentery bacillus infection of the bowel. In these
cases of chronic infection, instead of there being
superficial ulceration of the bowel, the organism
is buried in the walls and causes deep inacces-
sible infection, pitted scars and pustules. I do not
think any drug has been found to dislodge ihem
from their emplacement in the bowel wall. It is
also our experience that sulfonamides have no
benefit in chronic Salmonella infection of the
bowel. It is interesting that many of these cases
which have chronic bacillus paratyphosus B infec-
tion have given no history of paratyphoid fever
and no history of acute dysentery, but started in-
sidiously and became chronic, in some cases over
periods varying from three months to six years.

Dr. Watt (In closing) : I would like to thank

Drs. D’Antoni and Silverman for their remarks
and to add a short comment on two phases of the
discussion.

The use of multiple specimens as described by
Dr. D’Antoni will give a greater number of posi-
tive results in cases than will single cultures. The
rectal swab technic is not a substitute for .he
method he uses but rather a simple procedure
which provides reliable diagnostic information in
a high percentage of the cases of acute diarrhea
seen by the physician. These methods of diagnosis
are related to each other in much the same way
as a simple sputum examination is related to the
more elaboate technic of bronchoscopy. The sim-
ple examination is frequently an indication for the
more complex.

Dr. Silverman’s finding of a large number of
Salmonella paratyphoid D infections is very inter-
esting. To date, we have isolated some 26 differ-
ent Salmonella types from the cases seen at Char-
ity Hospital. The predominating type has varied
from time to time. Early in the study £>. viewport
was the most commonly encountered type, at pres-
ent S. panama is being isolated most frequently.
The clinical significance and the epidemiologic im-
portance of the various types is not well known
at the present time. About all that has been
established with certainty is that some types are
encountered more frequently in acute diarrheal
disorders, while others tend to invade the blood
stream and give a typhoid-like picture.

In closing, may I express my appreciation to
you, the members of the Orleasn Parish Medical
Society, for the privilege of presenting this paper
at your meeting.

Rollings and Musser — Meningitis

445

COMPARISON OF INCIDENCE AND
TREATMENT OF MENINGITIS
OVER A TEN YEAR PERIOD*

H. E. ROLLINGS, M. D.f
and

J. H. MUSSER, M. D.f
New Orleans

This study was carried out in an effort
to evaluate changes and progress in the
treatment of meningitis since the advent of
the sulfonamides in particular and, by com-
parison of mortality rates, duration of
fever in convalescence, sequelae, and com-
plications, to show what difference our
present methods of therapy have made in
meningitis. The material used is from the
case records of Charity Hospital of Louis-
iana at New Orleans and the years of 1933
and 1943 were chosen for the study so that
progress over a ten year period could be
studied, thereby providing a comparison of
two periods not too far apart, in which the
disposition of the cases was similar except
for- the to be evaluated alterations in plan
of1 treatment. Although the expected
changes derived from the use of the ther-
apeutic measures available in 1943 lay in
the treatment of the septic meningitides,
for completeness of the study, all cases were
included where a reasonably well proved
meningitis, septic or not, existed. Where
the etiology was determined, the meningitis
is classified under a specific etiology; the
remainder are grouped as undifferentiated
meningitides. Many of these latter pos-
sessed features suggesting a specific etiol-
ogy, but unless the organism was identified
bacteriologically or the course (as in lym-
phocytic choriomeningitis) was unmistak-
able, or the diagnosis was proved patho-
logically, that case is included in the undif-
ferentiated group.

In reviewing the case records, a consid-
erable difference in the incidence of menin-
gitis in general as well as in the specific
types of meningitis was observed. There

"Read before the Orleans Parish Medical Soci-
ety, March 12, 1945.

fFrom the Department of Medicine, Tulane Uni-
versity School of Medicine, and the Charity Hos-
pital of Louisiana, New Orleans.

were 55,437 admissions to the hospital in
1933 and in only 53 of this number was a
diagnosis of meningitis made, whereas, in
1943 there were 42,105 admissions to the
hospital and in 139 of this number a diag-
nosis of meningitis was made. The follow-
ing table (table I) has been prepared to
show the comparison of incidence in the
years studied showing the number of cases
occurring and their percentage relationship
to the total number of admissions for that

year.

TABLE 1

1933

1943

Total admissions ...

55,437

42.105

3

,o

O

Number of
cases

Per cent of
admissions

Number of
cases

Per cent of
admissions

Total cases of meningitis 53

.09

139

.33

Meningococcal

... 20

.035

53

.125

Pneumococcal

6

.010

25

.059

Influenzal

3

.005

17

.0406

Tuberculous

2

.0035

16

4

.039

.0095

Staphylococcal

2

.0035

Streptococcal

7

.012

1

.0023

Torula

0

0

1

.0023

B. pyocyaneus

1

.0017

o

0

.0040

Choriomeningitis

0

0

2

Aseptic (post

encephalography )

0

0

1

.0023

.0023

Luetic

0

0

1

Undifferentiated

12

.020

18

.042

In table 1 the increase in the incidence of
meningitis in general is shown. The total
cases of meningitis admitted to the hospital
in 1933 comprised only 0.09 per cent of the
total admissions to the hospital while in
1943, meningitis accounted for 0.33 per
cent of the total admissions. This table also
shows the alterations in the incidence of
the specific types of meningitis, but it is
better shown in table 2, where the specific
types are compared to the number of cases
of meningitis.

Table 2 presents the data in regard to the
incidence of the various types of meningitis
showing the percentage relationship of the
incidence of the specific types of meningitis
to the total number of meningitis cases for
that year.

The data in table 2 show that in regard
to special types, the relative incidence of
meningococcal meningitis to be not signifi-
cantly altered ; but in marked contrast one

446

Rollings and Musser — Meningitis

TABLE 2
1933

Total cases of meningitis. 53

1943

139

— 7, rfl 0 > *r! CO

^ !C £ W -O ^ 2

CJ £ ^ *? Cl/ c

q £ « J- £ 5 r. C

Cfl £ w CUc £ c; Phoj

Meningococcal 20 37.7 53 38.4

Pneumococcal 6 11.3 25 18.3

Influenzal 3 5.6 17 12.2

Tuberculous 2 3.77 16 11.7

Staphylococcal 2 3.77 4 2.9

Streptococcal 7 12.45 1 .719

Torula 0 0 1 . .719

B. pyocyaneus 1 1.88 0 0

Choriomeningitis 0 0 2 1.4

Aseptic 0 0 1 .719

Luetic 0 0 l .719

Undifferentiated 12 22.6 18 12.09

notes a great increase in the number of
cases of pneumococcal, influenzal, and tu-
berculous meningitis. Before attempting to
evaluate this increase, the decrease in per-
centage of the undifferentiated types of
meningitis over the ten year period must be
explained. The improvement in diagnostic
methods relative to pneumococcic and influ-
enzal meningitis may be expected to have
facilitated more accurate diagnosis; how-
ever, little change in the effectiveness of
diagnostic determinations in tuberculous
meningitis were apparent. Thus one can
reasonably ascribe at least part of the in-
crease in two of the three mentioned spe-
cific types to improvement in diagnostic
methods. The decrease in the relative num-
ber of cases of staphylococcic and strep-
tococcic forms of meningitis is evident.

Since these latter varieties were found to
be so often secondary manifestations, it
may be offered that not only are sulfona-
mides of therapeutic value in septic menin-
gitis but perhaps they also have served to
decrease the incidence of certain types. This
premise, however, is weakened by the find-
ing of an increase in pneumococcal menin-
gitis which also, though much less frequent-
ly in 1943, occurred at times as a secondary
manifestation.

One fact not mentioned in the tables, but
of possibly considerable importance, is the
finding that all but one of the 17 cases of
influenzal meningitis occurring in 1943
were found to be caused by H. influenza

Type B. In the one case making the excep-
tion, the organism was unfortunately not
typed. The three cases of influenzal men-
ingitis occurring in 1933 were not typed.
All the cases of tuberculous meningitis in-
cluded in this series were proved at autopsy,
a characteristic basilar meningitis being
the rule, but a coincident tuberculoma being
found in one case in 1933. No sound clinical
criteria for the diagnosis of tuberculous
meningitis could be found in this study.
Chloride determinations varied so widely as
to be useless; Mantoux tests were some-
times negative in definite cases proved at
postmortem. Levinson’s test was negative
in some proved cases of tuberculous men-
ingitis and positive in some cases later
proved to be non-tuberculous. In most of
the cases of tuberculous meningitis, the
meningeal involvement was but part of a
picture of miliary tuberculosis.

After considering the various incidences
presented above, the most obvious way of
evaluating the effect of the therapeutic
methods in 1943 compared to those used ten
years previously seemed to be by studying
the percentage of fatalities for the two
periods. This was done, and the findings
are presented in table 3.

It may be seen from table 3 that the per-
centage of deaths due to all types of men-
ingitis decreased from 79.3 in 1933 to 49.7
in 1943 changing the expected survival rate
from one in five in 1933 to one in two in
1943. It is to be noted also that these fig-
ures are compiled using not only septic men-
ingitis but using tuberculous meningitis as
well. The latter, in fact, was the cause for
16 of the 69 total deaths due to meningitis
in 1943.

If the cases of tuberculous meningitis are
excluded from the compilation, the percent-
age of deaths due to all other types of men-
ingitis is found to be 76.9 in 1933 and the
corresponding figure for 1943 to be 43.8.
Even this latter figure is shocking, but upon
breaking the total down and analyzing each
type of meningitis separately the findings
are more encouraging. It was found, for
instance, that the percentage of deaths in
meningococcal meningitis was reduced from

Rollings and Musser — Meningitis

447

TABLE 3

1933 1943

Total Recovered Died Total Recovered Died

Cases

No.

Per cent

No.

Per cent

Cases

No.

Per cent

No.

Per cent

Meningococcal

20

6

30

14

70

53

44

83.01

9

16.99

Pneumococcal

6

0

0

6

100

25

7

28

18

72

Influenzal

3

1

3 3 V3

2

66%

17

5

29.3

12

70.7

Tuberculous

2

0

0

20

100

16

0

0

16

100

Staphylococcal

2

0

0

2

100

4

1

25

3

75

Streptococcal

7

0

0

7

100

1

0

0

1

100

Torula

0

0

0

0

0

1

0

0

1

100

B. pyocyaneus

1

0

0

1

100

0

0

0

0

0

Choriomeningitis ...

0

0

0

0

0

2

2

100

0

0

Aseptic

0

0

0

0

0

1

1

100

0

0

Luetic

0

0

0

0

0

1

0

0

1

100

Undifferentiated ...

12

4

331/3

8

66%

18

9

50

9

50

Total

53

11

20.7

42

79.3

139

.70

50.3

69

49.7

70 in 1933 to 16.99 in 1943, and that the 100
per cent mortality in pneumococcal menin-
gitis in 1933 was reduced to 72 per cent in
1943. The number of cases reviewed in this
series related to the less frequent types of
meningitis is too small to allow conclusions
to be drawn from their separate indications.

In considering the large number of deaths
occurring in both the years studied, it
should be noted that many of these patients
were in extremis on admission and had been
ill often for many days before being
brought to the hospital. Several of the
deaths in both years occurred while the
patients were in the process of being ad-
mitted to the hospital and before any treat-
ment was instituted. Such instances may
detract from the accuracy of the data re-
gardings deaths due to specific types but for
the group as a whole the error should be
fairly well equalized, giving an accurate re-
lationship between the two periods although
leaving the percentage of deaths at a some-
what greater number for both years than
should have occurred otherwise.

Aside from comparing the percentage of
deaths for the two periods, another cri-
terion to aid in evaluating effects of more
recent therapeutic measures was the com-
parison of the duration of illness in the
cases which survived.

Tables 4 and 5 were prepared to show the
duration of fever during convalescence,
counting from the day of admission to the
hospital, since this was, as a rule, the day
when treatment was begun.

TABLE 4
1933

s

c

Type of Meningitis £

p t/i
-§ &
.5 ^

ri 'o

Meningococcal 7

Influenzal 10

Undifferentiated 5

TABLE 5
1943

£

p

c

£

£ m
£ >*
C X5

S *s

Meningococcal 0

Pneumococcal 2

Influenzal 2

Staphylococcal 6

Choriomeningitis 4

Aseptic 16

Undifferentiated 5

o

gD

£

£

i< o

33

10

18

u

o

-O

£

p

p

£

16

14

54

6

4

16

6

Sh

01

£

p

15.5

10.0

11.0

O)

-Q

£

c

01

bfl w
a >>
~ c C
Oi

< o

4.3
4.6

20.5

6.0

4.0

16.0

3.4

In this comparison, only the data regard-
ing meningococcal, influenzal, and the un-
differentiated varieties are relevant, since
only in these three did any recoveries oc-
cur in 1933; the other data are presented
only incidentally.

The striking difference in the duration of
fever in meningococcal meningitis for the
two periods shows only partially the re-
markable difference in the response of the
patients to treatment. Whereas, in 1933
convalescence was at best a stormy, trying,
pessimistic, and often unexpected period, a
characteristic response with comparatively

448

Rollings and Musser — Meningitis

amazing improvement in the condition of
the patient was the expected rather than the
unusual in 1943.

When considering the actual methods of
therapy used during these two periods it
was found that only one worthy weapon was
available to the clinician in the treatment of
meningitis in 1933. This, of course, was
specific antiserum. Antimeningococcal se-
rum was extensively used, not only as the
only available agent against the meningo-
coccus; but, showing the desperation of the
therapeutist, it was even used when the
etiology of the meningitis was known to be
of another type, such as streptococcic for
instance where five of the seven cases in
1933 received antimeningococcal serum, na-
turally with no benefit. Pneumococcal an-
tiserum must have been poorly established
or seldom available in 1933, since only one
of the six cases (a Type III pneumococcus
found) received specific antiserum, and this
patient died. Of the three cases of influ-
enzal meningitis occurring in 1933 only one
received anti-influenzal serum, and this
was the only case surviving. Another evi-
dence of the feeling of futility that accom-
panied the treatment of meningitis in 1933
was the notation in two cases of the use of
injection of Pregl’s iodine and acriflavine
respectively into the carotid arteries bilater-
ally and simultaneously, the carotids being
exposed surgically. The fatal outcome was
not apparently influenced in either case.
Staphylococcal antitoxin was used in a case
of influenzal meningitis thought to be due
to staphylococcus because of the concurrent
presence of acute osteomyelitis; this case
also expired.

The number of serum reactions occurring
in 1933 was studied and it was found that
33 patients received antimeningococcal se-
rum and that nine of these (27.2 per cent)
had serum reactions varying in severity
from those of anaphylactic type nearly
causing death, to mild serum sickness oc-
curring during convalescence. In one case,
the death of the patient was attributed to
the administration of serum, resulting in a
fatal reaction in spite of negative sensitivity
tests. The total percentage of serum re-

actions from antimeningococcal serum was
found to be 27.2. No untoward reactions
followed the use of antipneumococcic, anti-
influenzal, or antistaphylococcic serum
(each was used only once).

In contrast to the picture in 1933, it was
found that only ten years later serum was
not used alone in a single case. A number
of patients did receive serum, of course, but
always as adjuvant therapy to sulfona-
mides. The “repeated tap” method that
was used on all patients a decade ago, was
used only very occasionally in 1943. Often,
in fact, no further spinal taps were done
after the initial diagnostic one and, thus,
what previously was done as both a diag-
nostic and therapeutic procedure has be-
come largely a diagnostic procedure. One
sees no more a chart recording 40 spinal
taps under “therapy” on a meningitis chart.

The only cases of meningitis occurring in
1943 in which sulfonamides were not used,
were three cases of tuberculous meningitis,
one case of luetic meningitis, and those
cases in which the patient died before ther-
apy could be instituted. Sulfadiazine was
by far the most widely used drug in this
series, although several other sulfonamides
were used occasionally. Table 6 shows the
relationship of the various drugs in respect
to the number of cases applying.

TABLE

6

Sulfa-

Sulfa-

Sulfa-

Sulfa-

Sulfa-

th

ia-

pyra-

pyri-

meth-

diazi

ne

zole

zine

dine

azene

-a

’V

*0

'V

a>

Of

TJ

0»

T3

a>

TJ

oi 'd

>

>

0J

>

QJ

>

a»

> V

Q

ij

Q

a

Q

J Q

Meningococcal

37

8

4

0

2

0

1

0

0 0

Pneumococcal

7

9

0

5

0

2

0

0

0 1

Influenzal

4

10

1

0

0

2

0

0

0 0

Tuberculous

0

10

0

1

0

1

0

1

0 0

Staphylococcal

1

2

0

1

0

0

0

0

0 0

Streptococcal

0

1

0

0

0

0

0

0

0 0

Torula

0

1

0

0

0

0

0

0

0 0

Choriomeningitis

1

0

0

0

0

0

0

0

0 0

Aseptic

1

0

0

0

0

0

0

0

0 0

Luetic

0

0

0

0

0

0

0

0

0 0

Undifferentiated

7

6

0

2

1

0

1

0

0 0

Total

58

47

5

7

3

5

2

1

0 1

No attempt was made to draw conclusions
regarding special value of the specific drugs
from table 6 since the number of cases re-
ceiving other than sulfadiazine was so small
by comparison, but the table shows well the
pre-eminence of sulfadiazine as the princi-

Rollings and Musser — Meningitis

449

pal sulfonamide used in these cases.

The next point inviting study was the
number of reactions to the sulfonamides.
Of 129 patients receiving sulfonamide ther-
apy, 20 patients had untoward reactions to
the drug used (15.5 per cent). Only five
types of untoward reactions were observed,
namely: anuria; drug eruption, hematuria,
drug fever, and agranulocytosis. In 105
patients receiving sulfadiazine, there were
13 untoward reactions (12.3 per cent) and,
of these, nine consisted of hematuria oc-
curring in acid urine, two of hematuria in
alkaline urine, and two of so-called drug
fever. One of the nine cases of hematuria
in acid urine developed anuria, but this lat-
ter was overcome. Two untoward reactions
were observed following the use of sulfa-
thiazole out of a total number of twelve
cases (16.6 per cent) and of these one had
hematuria in acid urine and one had so-
called drug fever, one other patient devel-
oped a drug rash after changing from sulfa-
diazine to sulfathiazole. The one case of
agranulocytosis occurred following the use
of sulfapyrazine and promptly recovered
after discontinuing the drug and institution
of proper treatment for granulocytopenia.
Two reactions were seen following the use
of both sulfadiazine and sulfathiazole in the
same patients and both of these reactions
consisted of hematuria in acid urine. Two
similar reactions occurred following the
combined use of sulfadiazine and sulfanila-
mide. It is of interest that no deaths in
this study were attributed to untoward re-
actions to sulfonamides and in only a very
occasional instance was there a serious
enough reaction to require discontinuance
of the drug. Also of interest is the finding
that of the 15 cases of hematuria, only two
(13.3 per cent) occurred Avhen the urine
was alkaline and even in these two there
was no evidence to show that the urine was
alkaline at the time the actual damage was
done. No direct correlation between blood
level of the sulfonamide and untoward re-
action could be drawn.

Hematuria also occurred with blood
levels as low as 4.6 mg. per cent and was
absent in patients with as high a level as

46 mg. per cent. The sulfonamide level in
the case of agranulocytosis was 3.1 mg. per
cent, and in the cases of drug fever the drug
level averaged 11.4 mg. per cent. The single
case of "anuria occurred with a sulfadiazine
level of 29.5 mg. per cent.

No longer was antiserum or antitoxin
found to occupy the pre-eminent position as
the most potent therapeutic force against
meningitis, but it still occupies a place of
importance as an adjunct to sulfonamide
therapy. The use of serum in 1933 has al-
ready been discussed and its singular im-
portance verified. In 1943, serum was used
in 13 of the 53 cases of meningococcic men-
ingitis and of these 11 lived and two died.
Fourteen cases of pneumococcal meningitis
received serum and of these five lived and
nine died, but one must remember that only
seven cases of pneumococcal meningitis re-
covered. Eight patients with influenzal
meningitis received serum and of these four
lived and four died, but here too one must
consider that only five persons with influ-
enzal meningitis survived. Serum was used
in two cases of undifferentiated meningitis
(one case received pneumococcal antiserum
and one meningococcal antitoxin) because
of certain clinical features of these cases.
Both recovered, but the etiologic agent of
the meningitis was never determined. The
only case of staphylococcal meningitis to
recover received staphylococcal antitoxin in
conjunction with sulfonamide therapy.
Table 7 shows the distribution of the cases
receiving specific antisera.

TABLE 7

C/2
V

a/

>
o

ZJ
(V

PS

Meningococcic .... 44
Pneumococcic .... 7

Influenzal 5

Total 56

From these data it is apparent that spe-
cific antisera is of definite value in the
treatment of influenzal meningitis, since 80
per cent of the recoveries received anti-
serum and only 33 1/3 per cent of the fatali-
ties received it; one may also accept the
value of pneumococcic antiserum on similar

0) a>
a ^ x

a

(U

« 0!

11 (25%)

9

2 (22.2%)

5 (71.4% )

18

9 (50%)

4 (80%)

12

4 (33.3%)

20 (35.7% )

39

15 (38.5%)

450

Rollings and Musser — Meningitis

but less pronounced relationship. The value
of antimeningococcic serum (actually men-
ingococcic antitoxin) is not so well shown,
but one must remember that peculiar dif-
ference which a compilation of data cannot
show, that is, the fact that only the most
desperate cases of meningococcic meningitis
received antitoxin, and with this considera-
tion in mind, one is justified in believing
that meningococcic antitoxin is of definite
value when used within its well understood
limitations and in proper amounts.

Other methods of therapy for meningitis
that presented were : namely, “promine”,
as used in two cases of tuberculous menin-
gitis, without effect; bismuth, used success-
fully in one case of luetic meningitis, and in
the case of torula meningitis, iodides, bis-
muth, and arsenicals, without effect. Two
patients in this study were given penicillin
in conjunction with sulfonamide therapy;
one of these patients who had an undiffer-
entiated meningitis survived, and the other
patients who had infection with pneumo-
coccus failed to recover.

In studying the serum reactions occur-
ring in 1943 it was observed that of 38 pa-
tients receiving serum, 14 had reactions,
giving a rate of 36.8 per cent for serum re-
actions in 1943 as compared to 27.2 per cent
in 1933. Of the serum reactions in 1943,
nine of the total were due to meningococcal
antitoxin, four were due to antipneumococ-
cic serum, and one questionable reaction
was due to anti-influenzal serum. None of
the serum reactions in 1943 resulted fatally
and in general they seemed less severe than
those occurring in 1933.

The complications occurring in patients
with meningitis were tabulated and it was
noted that in 12 of the 53 patients studied
in 1933, complications occurred which could
rationally be thought related to the primary
disease. Oddly, pneumonia was diagnosed
(or recorded) in only one case premortem
though it was found in a large percentage
of the cases at autopsy. Distention was
cause for concern in three cases, mastoiditis
in one case, sinusitis (unspecified) in two,
otitis media in four, and cranial osteomye-
litis in one case. Of the 139 cases studied

in 1943 it was found that 20 cases had re-
lated complications. Nine of these patients
were diagnosed as having pneumonia, and
of these one had a pleural effusion. One
patient developed pulmonary infarction ;
one had diabetic acidosis, one a gluteal car-
buncle, one was ascribed to have nephritis
(non-sulfonamide) but the record is in-
conclusive. Seven cases of otitis media as a
complicating factor were observed.

SEQUELAE

A study of sequelae of this group of dis-
eases was attempted. Unfortunately the
follow-up of such a group is generally very
poor as would be expected by the very na-
ture of the disease and, therefore, this study
is recognized to be deficient. Nevertheless,
the findings will be presented. The 1933
records especially were inadequate, since
clinic records were seldom available and in
that group the only sequelae recorded were
of three cases of polyarthritis and three
cases of persistently positive nasopharyn-
geal cultures for meningococcus. In 1943,
the clinic records were more readily obtain-
able and record was found of 15 cases where
sequelae occurred. The following is a list
of the sequelae which were recorded :

Partial paralysis of left deltoid and su-
praspinatus muscles.

Bilateral deafness; polyarthritis after a
serum reaction.

Unilateral seventh and eighth nerve
palsy.

Hallucinosis and euphoria.

Deafness, bilateral; and cerebral atrophy
(proved by encephalogram).

Joint pains and profuse sweats (no se-
rum used in this case).

Polyarthritis (no serum used in this
case) .

Weakened ocular convergence.

“Bad child” — evident behavior disorder,
which eventually was relieved.

Burning of eyes for weeks.

Polyarthritis (no serum given to this pa-
tient) .

Partial left hemiplegia with paralysis of
left deltoid.

Stupidity (previous state uncertain).

Rollings and Musser — Meningitis

451

Sixth nervy palsy.

Corneal ulcer.

SUMMARY

In an effort to study the effects of sul-
fonamide drugs in the treatment of menin-
gitis, all cases of meningitis in the Charity
Hospital in 1933 were compared with all
cases of meningitis occurring in 1943. No
selection of cases was made other than to
avoid inclusion of cases where the diagnosis
of meningitis was unsatisfactorily proved.
Meningitis was classified etiologically and
those cases where the etiologic agent was
not proved, were grouped under “undiffer-
entiated meningitis.” The incidence of the
various types was presented, the percentage
of deaths in the various types was compared
for the two years. The incidence of menin-
gitis in general was shown in its relation-
ship to the total number of admissions to
the hospital. The period of convalescence
was compared. The therapeutic methods
were presented briefly and a comparison of
results and untoward reactions to the thera-
peutic agents shown. The complications of
meningitis during both periods were pre-
sented as were the sequelae. As much of
the data as possible were presented in tabu-
lar form and brief supplementary remarks
were made where the tables were not self-
explanatory.

DISCUSSION

Dr. P. H. Jones: Meningitis some fifty years ago
was spoken of in two groups: meningococcal, that
meningitis sometimes got well; the other types did
not. It was seen from the doctors’ interesting pa-
per that we have moved a long way in the field
of treatment since then.

Dr. John H. Musser : Mr. President, to my mind
there are two things of paramount interest in this
report which we presented to you tonight. In the
first place I am unable to explain the increasing
incidence of meningitis. You will note that not
only has meningococcic meningitis increased in the
actual number of cases but also that other types
of meningitis have also increased. Dr. Rollings
has suggested, in talking these things over with
me in preparing the paper, that this might be due
to the fact that at the present time we are keener
in our diagnostic acumen and able to . recognize
cases of meningitis sooner than we were able to
do ten years ago. I doubt this very much. I think
you will appreciate and realize, those of you who
have worked in the contagious wards in Charity,

that we were just about as ready to do lumbar
punctures then as at the present time. The punc-
ture is essential to make the diagnosis; as my
old professor once remarked — “the diagnosis flows
out of the needle,” which is perfectly true. Of
course in wartime for some peculiar reason, menin-
gitis is on the increase not only in army camps
but also in the civilian population. I can see very
well why meningococcic meningitis is on the in-
crease but can not explain the reason pneumococcic
meningitis has increased or why there are more
cases of tuberculous meningitis.

The second thing which I think of decided im-
portance is the question of the sulfonamides in the
treatment of meningitis and more particularly the
effects of penicillin. As Dr. Rollings pointed out,
we have not had very much opportunity of using
penicillin. We have used it more in the past year
since it has become available than we did in 1943
but I do not think the results are a bit more sat-
isfactory than they are with sulfonamides. As a
matter of fact, in an article written by Dr. Fran-
cis Blake published in last week’s J.A.M.A., he
said the sulfonamides are better drugs than peni-
cillin in meningococcus meningitis. I think that
statement goes with our ideas about the treatment
of this disease.

In adults I recommend that the patients be given
sulfonamides by mouth or intravenously if they
can not be taken by mouth. Practically all the
patients take the drug by mouth after the first
forty-eight hours. Then give “booster” doses of
penicillin intrathecally if there is not a satisfac-
tory response to sulfonamides. The penicillin
works so beautifully when applied locally in septic
conditions I think it helps materially in clearing-
out organisms in the spinal fluid.

Our recovery figures are not quite as dramatic
or remarkable as some from the army camps. On
the other hand I hope you will realize and appre-
ciate many of the patients we get at Charitp Hos-
pital are in extremis when they come into the hos-
pital. In army camps as soon as a boy has a
headache or feels badly he reports to the medical
officer, the battalion surgeon. Their cases are
seen much earlier than ours.

Our results in the past were poor as contrasted
with other places. About the time of this analysis
of the first ten year period Dr. Tripoli read a
paper before the A. M. A. section on medicine
upon the treatment of meningitis. We were rath-
er criticized because our mortality rate was much
higher than in, say New York City. I might say,
in extenuation, that in New York City the City
Board of Health at that time had a meningitis
department, Dr. Josephine Neal heading it. Irre-
spective of the patient’s economic place in life, it
helped the private physicians with their patients
who received treatment early and received it more
definitely and positively, more thoroughly and
more properly than would the patient being seen

Hyslop — Inadequate Ascorbic Acid Intake

452

on the outside here in New Orleans and the sur-
rounding districts.

The recent results of treatment have been so
remarkable that I have heard it said among the
laity that meningitis now is not as bad as having
a bad cold. I will say, however, that within the
last several months we have had three or four
very typical fulminating cases with marked delir-
ium, death occurring in eighteen to thirty-six
hours. I have a sort of idea, which may be wrong,
that in so far as meningococcic meningitis is con-
cerned, the present strain is not as virulent as in
the past. There is a possibility that it may be-
come more virulent and that the fulminating cases
now appearing suggest this possibility.

One last remark — I think that it is a good idea
to give antitoxin to patients promptly. When pa-
tients come in markedly prostrated, sometimes
wildly delirious, sometimes in coma, if given one
hundred thousand units of antitoxin intravenously
and then followed several hours later by sulfadia-
zine, better results will be achieved than achieved
in the past. We have not made this a routine.
I think it is something to which we should give
serious thought, as well as the use of penicillin in
conjunction with sulfa drugs.

Dr. Gilbert C. Anderson: Mr. President, gentle-
men, I have nothing of value to add. This is
largely reminiscent with me because I was prob-
ably responsible for the injection of the iodine
preparation and the dye stuffs directly into the
carotid arteries. I remember we did on several
patients in Charity and at the Nose and Throat
Hospital with the late Dr. Lynch with no apparent
result on the progress of the disease. Just here
of late I have been unfortunate enough to be
associated with two cases of rather fulminating
pneumococcic meningitis that did not respond to
intensive treatment either with chemotherapy or
molds or, as a matter of fact, with a combination
of both; even to the point of treatment by cis-
ternal puncture. It has been given, as you know,
in a few instances by direct installation into the
ventricles but I saw lately reported very severe
reactions following that particular type of therapy
with a note of warning sounded against it. The
most remarkable difference that I can see is at
the Ear, Nose and Throat Hospital — I have been
on the staff there a long time and often used to
be called when they had intracranial complica-
tions from sinuses, mastoid and middle ear and so
forth, probably several times a month. I don’t
believe I have been called down there five times
within the past year which I attribute largely to
new type of therapy.

That one fact emphasizes very well the contrast
between 1933 and 1943 in therapy of intrathecal
suppuration.

Dr. R. V. Platou : I would like to suggest that
the increase of meningitis in wartime is apparently

due to a rapid shift in population. This is shown
by increased numbers of carriers and cases when
new recruits come into camps or aboard ships.
With such migrations there is almost always an
increase in carrier rate and incidence of clinical
streptococcal and meningococcal infection. This
increase is not easy to explain but is probably re-
lated to crowding, agitation, shifting, and mixtures
of population which do not take place in peacetime.

I would like to say a few words about intra-
thecal penicillin. We have agreed that the results
of treatment with sulfonamides and specific anti-
sera are as good or better than with penicillin
except in two particular situations: when the case
of meningitis is due to sulfonamide-resistant strain
of meningococcus or when pneumococcal meningitis
occurs in an infant or young child. With specific
serum-sulfonamide treatment the mortality rate
for pneumococcal meningitis in young children un-
der three years of age still approaches seventy per
cent. We have used intrathecal penicillin in sev-
eral of these cases, giving it at intervals of twelve
and twenty-four hours in doses of twenty to forty
thousand units. While it is too early to say what
the eventual prognosis will be with penicillin, the
results seem to be good so far — better than any
yet employed.

0

THE EFFECTS OF INADEQUATE
ASCORBIC ACID INTAKE

HENRY R. HYSLOP, M. D.

New Orleans

history

Scurvy is believed to have occurred
among the armies of ancient times. Pliny
states that the Roman Army under Caesar
Germanicus, after an encampment of two
years in Germany, suffered with a disease
in which the teeth dropped out and the
knees became paralytic. Similar refer-
ences can be found in the works of Hippoc-
rates, Strato, Celsus, and Galen. However,
all the descriptions of this disease offered
by these men were too vague to identify
them with certainty as scurvy.1

The first good description of scurvy is
found in the history of Louis IX by Le
Sieur de Joinville who wrote of the disease
in the army of Christian Crusaders in
Egypt in about the year of 1260. 1 How-
ever, the first description written by a
physician is found in a letter sent in 1541
by one Ectheus to Dr. Blienburchius of At-

Hyslop — Inadequate Ascorbic Acid Intake

453

recht. The first book completely devoted
to scurvy was written by Balurn Ronsseus
in 1564. 2

Numerous accounts are found in the older
writings of the ravages of this disease and
of the great losses of men which occurred
in all long sea voyages. Practically no ex-
plorer or historian fails to mention the
great death toll claimed by scurvy.

It is very interesting to find, even in the
earliest of these writings, with what con-
stant reiteration the juice of lemons or
orange, green herbs, brooklime, watercress,
and fresh vegetables are described as spe-
cific cures for this disease. At the same
time it is astonishing that conditions were
not improved to prevent this life taking
malady, even in spite of the knowledge of
a specific cure.1' 2> 3

To James Lind, with the collaboration of
Sir Gilbert Blane, James Cook, and Thomas
Trotter goes the credit for having amassed
the greatest amount of convincing evidence
as to the nature of scurvy. It was through
this influence that the British Navy intro-
duced lemon juice in the rations of sail-
ors as a prevention against scurvy in
1795. - 3’ 4

It was not until 1928, however, that
Szent-Gyorgii isolated from the suprarenal
glands of oxen and from various plant
sources the crystalline compound which he
called hexonuric acid and is now known as
vitamin C, cevitamic acid, or ascorbic acid.
In 1932 he proved this compound to be the
specific antiscorbutic factor.8

Many other names enter into the history
of scurvy and ascorbic acid, but a detailed
account is beyond the scope of this paper.
Reference is made to other sources for a
complete history on this subject.

INCIDENCE

Croft and Snorfr> report the incidence of
cevitamic acid deficiency in 100 unselected
patients. They found that 38 had plasma
ascorbic acid concentrations below 0.40 mg.
per cent as determined by the method of
Farmer and Ott. The remaining 62 pa-
tients had vitamin. C concentrations rang-
ing from 0.40 to 1.55 with an average of

0.71 mg. per cent. The lower limit of nor-
mal in this study was a plasma concentra-
tion of 0.40 mg. per cent.

It is interesting to note that the majority
of plasma ascorbic acid concentrations were
made on patients who were of an economic
and social status that would presuppose a
sufficiency of the deserved diet. As a re-
sult they concluded that moderate to severe
grade of inadequate intake of ascorbic acid
is not uncommon among people economical-
ly able to obtain a sufficiency of foods
which presumably would prevent it. Anoth-
er interesting observation made during
this study was that extremely low plasma
concentrations of cevitamic acid may exist
without striking clinical manifestations.

In 1942 Baumann and Brook0 reported
the incidence of vitamin C deficiency in
European and colored school children of
the Cape Peninsula between the ages of
eight and sixteen. In determining the de-
ficiency state they used the method of
Wright Lilienfeld and MacLenathen for the
intravenous saturation test and the method
of Gothlin for capillary fragility test. They
found that a definite deficiency state was
present in 21.1 per cent of European child-
ren and 7.4 per cent in colored children.
The total number of children examined was
380. These authors conclude that in gen-
eral there is very little evidence of ascorbic
acid deficiency in the children examined.

As a result of the war with its effects
on nutrition, there has been an increase of
deficiency states in school children, medical
students and scientific workers, though the
latter two groups have been affected less
than the former. However, there has been
a decided increase in the incidence and de-
gree of deficiency in the latter groups with-
in the last few years of the war.7- 8

There is also a seasonal variation in the
incidence of cevitamic acid and deficiency,
the levels of plasma ascorbic acid concen-
trations being low after the winter months
and much better after the summer. The
basis for making this statement lies in the
results of studies7, 9 carried out on school
children, medical students, scientific work-
ers and unselected hospital patients.

454

HYSLOP — Inadequate Ascorbic Acid Intake

PATHOLOGY

The primary morphologic effects of vita-
min C deficiency occur in the intercellular
substances of certain mesenchymal deriva-
tives. The basic defect is in the formation
of fibrils in the intercellular matrix of the
fibroblasts. This defect occurs not only in
soft tissues but also in osteoid tissue, den-
tin and it is believed to occur in blood ves-
sels. There is also a tendency for defective
materials to form in connective tissue in
partial depletion and for nothing of a sub-
stantial nature to form in complete deple-
tion of ascorbic acid.10' 11

In the capillaries morphologic changes
have not been detected and it is doubtful
whether they occur. Where the lesion oc-
curs in the capillaries is not known. It
may occur in the sheath or in the cement
substance between endothelial cells.11

The anatomic manifestations of scurvy
are greatly modified by twTo factors, growth
and stress. These are of extreme import-
ance to the pathology of ascorbic acid de-
ficiency.11

The growth factor and its influence on
the morbid anatomy of scurvy was the rea-
son why for many years this disease was
considered a variety of rickets. Hemato-
mas became less and less frequent as the
age of the patient increased. Osteoporosis
is greatly intensified in the young animal
just as it is always most pronounced at a
particular part of bone where growth is
more active.11

Stress modifies the site of lesions and de-
termines the extent and involvement of the
various structures. Stress plays a major
part in determining the site of the hem-
orrhages and where other changes in muscle
will occur.11

The lesions are also indirectly modified
by other factors, for example the presence
or absence of a variety of other diseases
and disturbances associated with an in-
creased metabolic rate. These may operate
similarly to growth and physical stress in
determining the requirements of vitamin
C and, therefore, indirectly, the extent and
degree of scorbutic lesions.

Skeletal lesions are commonest in the
costochondral junctions, the distal end of
the femur, the proximal end of the tibia,
femur and wrist. In the affected regions
bone formation ceases and the existing
bony shell becomes rarefied, widened and
conical. The epiphysis is not affected in
early stages but may become displaced. Mi-
croscopic examination reveals a rarefaction
of the existing cortex, cessation of bone
growth and replacement of the normal
junction by a zone of collagen-poor con-
nective tissue in which are embedded frag-
ments of densely calcified cartilage matrix.
Frequently these lesions are complicated by
hemorrhages, either large subperiosteal
ones, or small ecchymosis within ®r along
the bone. The extent of the lesions, of
couse, depends on the degree of deficiency,
on stress, on growth and on incidental fac-
tors.1' 1011 Mouriquand and Edel12 report
on the great incidence of decalcification of
the neck of the femur which suggests that
this location is a place of particularly low
resistance to vitamin C deficiency. They
consider that this observation is important
because of the resemblance of this condi-
tion to certain clinical syndromes encoun-
tered in children and old people.

In the teeth of adults with scurvy, the
dentin is seen to be resorbed and parotic.
The little replacement dentin that may be
formed is inferior in appearance. The le-
sions develop first in the apex of the tooth
and bifurcation of the root canal. The ce-
mentum is similarly affected. Lesions of
the gingiva occur only when teeth are pres-
ent and are most severe about deformed or
broken teeth. The gums become boggy,
swollen and bleed easily. Rarefaction of
the alveolar bones results in the loosening
of teeth. The gingival lesions commence on
the papillae, first as a hypermia followed
by disintegration of the epithelium, infec-
tion with ulceration, granulations and even
gangrene.1, 10’ 11

In muscle fragmentation of striated fibers
and intense reparative efforts marked by
multiplication of the sarcolemma occur.
Spontaneous hemorrhages also occur within
the muscle. In the eyes, hemorrhagic mani-

Hyslop — Inadequate Ascorbic Acid Intake

455

festations appear on the conjunctiva, eye-
lids and elsewhere about the eyes. In the
skin the characteristic manifestation is a
perifollicular or petechial hemorrhage.
These are most common in the lower ex-
tremities or wherever pressure exposes the
weakness of the capillaries.10' 12

Other common lesions are bloody effu-
sions into serous cavities, edema of ankles,
enlargement of the heart, and atrophy of
bone marrow. The adrenals atrophy as a
result of absorption of corporal fat and as-
corbic acid. Atrophy of the lymphatic tis-
sue and to a lesser extent of other organs
especially glands of internal secretion may
occur.10

SYMPTOMATOLOGY

The manifestations of ascorbic acid de-
ficiency depend to some extent on the age
of the patient. This has already been men-
tioned above. Infantile scurvy differs from
adult scurvy principally in the extent to
which the growing bones are involved, but
discrepancies in morphology and symptom-
atology based on the patient’s age level do
not justify separation of the resulting syn-
dromes into two entities.3

The symptoms of this disease begin, as a
rule insidiously with a feeling of general
weakness and inadequacy, negativism, de-
pression and even melancholia. The nor-
mal degree of alertness is replaced by a dis-
position of inactivity, the patient preferring
to sit down or lie about. Anorexia develops
which is further enhanced by painful gums.
The skin is rough and dry and it may take
on a waxy appearance. Soon in addition
to the fatigue, there are breathlessness and
dull aching pains in the legs and feet. In-
stead of pain, the patient may complain of
stiffness of the knees or feebleness of leg
muscles. 3- 14> 15

The lips become cyanotic, the gums be-
come very red and spongy and bleed upon
the slightest provocation. The swelling be-
gins first and is most intense in the lower
jaw and usually beginning about the molar
teeth and progressing forward. The swollen
tissue next ulcerates and breaks down, often
sloughing away until the necks of the teeth
are left bare. The teeth become loose and

often fall out. The breath becomes exceed-
ingly offensive.7’ 11

The characteristic hemorrhages appear
first as petechial spots, later these spots be-
come larger. The spots may be of all
colors; red when the effusion first occurs,
later becoming purplish, and varying
greenish-blue to dusky yellow as they be-
come absorbed. The spots are not painful
or tender on pressure unless there is at the
same time effusion into muscles. If the
disease proceeds untreated there is a tend-
ency for these hemorrhagic areas to ul-
cerate, particularly when on the legs.1- 14

The lower extremities develop swellings
in the muscle masses, particularly in the
extensors and adductors of the thighs and
in the calves, as a result the knees are held
in partial flexion ; efforts toward full exten-
sion are accompanied by great pain. These
symptoms are due to hemorrhages into the
"muscle as well as to under the periosteum.
Later a pitting edema will develop which at
times involves the whole extremity.1’ 3’ 14- 15

In severe cases there may be hemorrhage
from the nose, stomach or intestine, or an
extravasation of blood may suddenly appear
without provocation at some bizarre site as
in the orbit causing proptosis and ecchymo-
sis of the eyelids. Suppuration may de-
velop in any hematoma, leading to the for-
mation of huge abscesses. The pulse may
become rapid and weak, and the patient
may suddenly die from relatively mild phy-
sical exertion.3

Infants are usually fretful and take a mo-
tionless frog-like position of the lower
limbs. Anorexia is prominent. Fever is
common in contrast to adults who are as a
rule afebrile. Petechial hemorrhages are
generally less conspicuous than in the adult.
The tenderness of the involved extremities
and the changes in contour brought about
by subperiosteal hemorrhages and epiphy-
seal infarction are often extreme. On the
other hand, the oval signs are usually limit-
ed to swelling and purplish discoloration of
the gums.3’ 13

Anemia is always present both in infants
and adults, the picture being that of a
secondary anemia due to bleeding. The

456

Hyslop — Inadequate Ascorbic Acid Intake

leukocyte count may be normal but it is fre-
quently increased and counts from 20,000
to 50,000 have been recorded. The poly-
morphonuclears are relatively decreased
and there is a considerable increase in large
lymphocytes and monocytes.1

On x-ray the deficiency of intercellular
material is manifest in growing bone by
lack of matrix or osteid tissue at the dia-
physis immediately shaftward from the
zone of preparatory calcification. This ap-
pears in the x-ray as a zone of diminished
density or rarefaction which has become
known as the scorbutic lattice. The defec-
tive calcification at this zone predisposes to
posture and slipping of the epiphysis. At
the same time cessation of growth permits
an intensification of calcification at the
epiphyseal ends of long bones and at the
periphery of the epiphyseal centers of ossi-
fication which on x-ray appear as the white
lines of scurvy. Thinning of the cortex and
trabeculae of the shaft gives the bones a
ground glass appearance by x-ray. Finally
subperiosteal hemorrhages raise the peri-
osteum, giving a typical appearance.18

DEFICIENCY IN RELATION TO OTHER DISEASES

The state of vitamin C unsaturation ex-
isting in pulmonary tuberculosis has been
found so gross as to suggest some specific
relationship. Erwin, Wright and Doherty
attempted to discover the relationship,
stimulated by the reports of several investi-
gators on the improvement of tuberculous
patients following vitamin C administra-
tion. These workers saturated their pa-
tients with ascorbic acid and evaluated
whatever improvement might occur. After
careful study they concluded that the hy-
povitaminosis found is a result of toxemia
and non-specific. Ascorbic acid has no
value in the treatment of tuberculosis or its
complications. These findings are in con-
trast to those of Albrecht and Weber1*1 who
did find some improvement in allowing ad-
ministration of cevitamic acid.

It has been noted that practically all cases
infected with intestinal fusospirochetes
have a history of a vitamin C deficiency
diet. In attempting to find the correlation

between these two diseases it was found
that a deficiency of cevitamic acid may
cause a break in the intestinal mucosa
which allows for the entrance of the fuso-
spirochete into the intestinal wall.17

It has been presumed that a patient on a
vitamin C deficient diet would develop cer-
tain skin diseases, that is, that cevitamic
acid is one of the etiologic factors. A com-
plete and careful study was performed in
order to confirm or reject this presump-
tion by Lever and Talbott. ls These work-
ers determined the plasma ascorbic acid
levels, and correlated their findings with
the presence of a skin disease. This conclu-
sion to this experiment was that there is no
direct correlation between the level of vita-
min C in the blood and the development of
several diseases of the skin. Yet good re-
sults are obtained in the treatment of cer-
tain skin diseases by ascorbic acid adminis-
tration.111' 20

Vitamin C deficiency has been incrimi-
nated as a predisposing cause to excessive
lead absorption in workers who are exposed
to lead. Now, however, the general con-
sensus seems to be that deficiency of this
vitamin in no way predisposes to in-
creased lead absorption and that it is of no
value when given therapeutically in in-
creasing lead elimination.21

Antepartum hemorrhage in the first
trimester occurs in about 9 per cent of preg-
nancies and is most frequently associated
with the abortion state. Evidence is being
accumulated showing that the antihemorr-
hagic vitamins C and K may be factors in
the pathogenesis of certain of these cases.
Vitamin C administration in these cases
causes a decrease in the incidence of ante-
partum hemorrhage.22

An inadequate intake of ascorbic acid
definitely has a delaying effect on wound
healing. Experiments23 have definitely
proved that vitamin C is fundamental in the
regeneration of tissues. The tensile strength
of tissues is markedly decreased due to the
imperfect formation of collagen. Vitamin
C administration in deficient animals in-
creases the tensile strength to the same de-
gree as in normals, but in a non-defcient

Sloan — Hypertension

457

animal the tensile strength is not in-
creased.24

SUMMARY

The classical disease of inadequate ascor-
bic acid intake is scurvy, the pathology and
clinical manifestations of which are well
known and are described in this paper.

There is a great variation in the extent
and degree of the manifestations of ascor-
bic acid deficiency depending on such fac-
tors as growth, stress and the degree of
deficiency. Deficiency may be subclinical.

Ascorbic acid deficiency seems to have
little if any relationship to other pathologic
states in which it has been incriminated
with exception of antepartum hemorrhage
and faulty wound healing.

REFERENCES

1. Veddpr. E. I!. : Scurvy. Tice JTactiee of Medicine,
0:161, io:;t.

2. Yog ■), Karl : Scurvy "the plague of the sea and the
spoyle of mariners," Bull. New York Academy Med., 0 :459,
lOrlB.

3. Cecil, It. E. : Textbook of Medicine, W. B. Saunders
Co., Philadelphia, 1013, pp. 557-563.

4. Farrell, E. : Smollett, Lind, and Anson in 1730 : their
common contribution to control of scurvy, Am. ,1. Surg.,

40 :40G, 1030.

5. Croft, .1. D., and Snorf, L. D. : Cevitamic acid de-
ficiency. Frequency in a group of 1(10' unselected patients,
Am. .T. Med. Sci., 108 : 403, 1030.

6. Baumann, W. E.. and Brock. .7. F. : Vitamin C de-
ficiency in Cape Peninsula school children. So. African
J. Med., Sci.. 7 :212. 1!I42.

7. Harris, !.. .1. : Vitamin C levels of school children
and students in war time. Lancet, 1 :042, 1042.

S. Francis, (5. E., and Wormall, A. : Vitamin C scurvy
of medical students. Lancet, 1 :647, 1042.

0. Prunty, F. T. G.. and Voss. C. C. N. : Vitamin C nu-
trition in a hospital. Lancet, 1 :180, 1044.

10. Ilalldorf, <1. : The pathology of vitamin C deficiency,
,T. A. M. A.. Ill : 1 37 6. 103S.

11. Moore, It. A.: The pathology of deficiency states,
Med. Clin. No. Am.. 27:500, 1043.

12. Mouriquaud. (}.. Dauvergne, M., and Edel, V.: Osteo-
pathy from deficiency : “irreversible” decalcification of the
neck of the femur in chronic vitamin C deficiency, Press'*
Med., 48:268, 1040.

13. Butler, A. M. : Vitamin C deficiency, Med. Clin. No.
Am.. 27 :441, 1043.

14. Hollis, B. II. : Symposium on vitamin C deficiency,
Kentucky M. J., 41 :204, 1043.

15. DjIo, V. P. : An internist’s view of vitamin C defic-
iency. Idem : 270.

16. Edwin, G. S., Wright, It., and Doherty, C. J. : Hypo
vitaminosis C and pulmonary tuberculosis, Brit. Med. J..
1 :G88, 1040.

17. Woolsey, F. M.. and Black, ,T. R. : Vitamin C defic-
iency and intestinal fusospirochetosis, Arch. Path.. 2S :503,
1939.

18. Lever, W. F., and Talbott, .7. II.: Roll of vitamin C
in various cutaneous diseases. Arch. Bermat. & Syph.

41 :657, 1040.

10. Wolfe, M. M. : lthinophyma with new etcologic and
therapeutic considerations, Laryngoscope. 53 :172, 1043.

20. Way, S. C. : Colloid milium, a vitamin deficiency.
Arch. Dermat. & Syphilol., 45: 1148. 1042.

21. Evans, E. E.. Norwood, W. !>.. Ivehoe, R. A., and
Maclile, W. : The effects of ascorbic acid and relation to
lead absorption. .7. A. M. A.. 121 :501, 1043.

22. , Invert. C. T„ and Stander, H. .7. : Plasma vitamin C
and prothrombin concentration iu pregnancy and in threat-
ened, spontaneous and habitual abortion, Surg. G.vnee. &
Obstot., 76:115, 1943.

23. Bcume, G. II. : Vitamin C and repair of injured tis-
sues, Lancet, 2 :661. 1042.

24. Hartzell, J. B.. and Stone, W. E. : The relationship
of the concentration id’ ascorbic acid of the blood to the
tensile strength of wounds in animals, Surg. Gyriec. A
Obstet., 75:1, 1942.

0

PATHOGENESIS OF HYPERTENSION

WYMAN P. SLOAN, JR., M. D.

New Orleans

INTRODUCTION

Since Richard Bright7 in 1836 observed
the relationship between albuminous urine
and ventricular hypertrophy, there has been
a tendency to overemphasize the connec-
tion between hypertension and renal dis-
ease. This tendency has received added im-
petus of late through the experimental work
of Goldblatt,2S Page,45 Corcoran14 and oth-
ers.

It is not the purpose of this paper to at-
tempt in any way to belittle this relation-
ship. The purpose is rather to emphasize
the fact that all cases of high blood pres-
sure are not necessarily of an essential or
a renal nature. While, admittedly, the ma-
jority of hypertensive patients will fall into
these two categories, there are a number
of other important conditions which will
give rise to an increase in blood pressure.
These should be sought for before the diag-
nosis of “essential” hypertension is made.
It must be borne in mind that, quite often,
an increase in blood pressure is a symptom
of disease rather than a disease entity with-
in itself.

Normally there are five physiologic fac-
tors operating in the human body as blood
pressure determinants:4 (1) pumping ac-
tion of the heart ; (2) viscosity of the blood ;
(3) elasticity of the arterial walls; (4)
quantity of blood in the vascular tree and
(5) the peripheral resistance. Uncompen-
sated alteration of any of these factors may

458

Sloan — Hypertension

lower or raise the blood pressure. In an
attempt to simplify the explanation of the
pathogenesis of the hypertension in various
clinical disorders, a physiologic classifica-
tion is presented. The disease entity asso-
ciated with hypertension is classified under
the hemodynamal factor whose alteration
is chiefly responsible for the rise in pres-
sure. As in any classification, there is some
overlapping of categories, due to the fact
that in many of the pathologic conditions
more than one of the pressure determinants
is affected. Clinical and pathologic classi-
fications of hypertension have been pre-
sented by Volhard and Fahr,61 Keith,30
Schroeder and Steele.50 Kahler35 has given
us one with a physiologic basis.

CLASSIFICATION OF HYPERTENSION

I. Hypertension due to an alteration in
the pumping action of the heart.

1. Thyroid disease.

2. Tachycardia due to exertion, emo-
tion, and so on.

3. Aortic insufficiency.

4. Arteriovenous aneurysm.

5. Heart block.

II. Hypertension resulting from an in-
crease in blood viscosity.

1. Polycythemia vera.

III. Hypertension resulting from a decrease
in elasticity of the arterial walls.

1. Arteriosclerosis.

a. Senile.

b. Diabetic.

c. Lead poisoning.

IV. Hypertension resulting from an in-
creased quantity of blood.

A. Generalized increase.

1. Intravenous plasma, whole blood,
and acacia.

2. Adrenocortical tumor.

3. Cushing’s syndrome.

B. Localized.

1. Coarctation of the aorta.

V. Hypertension due to an increase in
peripheral resistance.

A. Associated with ischemia of vital

organs.

1. Brain.

a. Brain tumors.

b. Contusion of the brain.

c. Central arteriosclerosis.

2. Kidneys.

a. Acute and chronic glomeru-
lonephritis.

b. Polycystic kidney.

c. Hydronephrosis.

d. Prostatic obstruction.

e. Ureteral and urethral ob-
struction.

f. Renal artery embolism or
thrombosis.

g. Mercury poisoning.

h. Kidney infarcts.

i. Hypernephroma.

j. Perinephritis.

k. Hematoma.

l. Amyloidosis.

m. Periarteritis nodosa.

n. Nephroptosis.

o. Experimental.

p. Pyelonephritic contracted
kidney.

B. Associated with endocrine disturb-
ances.

1. Arrhenoblastoma.

2. Menopausal syndrome.

3. Pheochromocytoma.

C. Associated with nervous disturb-
ances.

1. Diencephalic syndrome.

2. “Nervous” hypertension.

3. Bulbar poliomyelitis.

D. Associated with an increase in body
mass.

1. Obesity.

2. Large tumors (fibroids).

3. Pregnancy.

4. Myxedema.

E. Idiopathic.

1. Benign.

2. Malignant.

DISCUSSION

I. Hypertension Due to Alteration in the
Pumping Action of the Heart: Hyperten-
sion due to alteration of this physiologic
mechanism is characterized by three clinical
findings: (1) increase in systolic pressure ;

(2) low or normal diastolic pressure, and

(3) an obvious increase in pulse pressure.

Sloan — Hypertension

459

The predominant cause of increased blood
pressure here is the increase in cardiac out-
put, being- in turn due to an increase in the
minute volume of the heart. The minute
volume is determined by two variable fac-
tors, that is: (1) the cardiac rate and (2)
the amount of venous return to the heart.
An increase in cardiac rate will not result
in an increase in the minute volume of the
heart without a concomitant adequate ven-
tricular filling4 which presupposes a great-
er venous return.

Thyrotoxicosis,19 simple tachycardia due
to emotion, or excitement, and arterioven-
ous aneurysms20 all result in an increase in
venous return to the heart. Thyrotoxicosis
and tachycardia exert their effect by speed-
ing up the circulatory rate in the body. An
arteriovenous aneurysm increases the car-
diac return by mechanical means. An in-
crease in venous return causes an increase
in the pressure of the great veins leading
to the heart, and, through a reflex mechan-
ism (Bainbridge reflex), the heart is ac-
celerated in rate. Thus, both factors upon
which the minute volume of the heart is
dependent are increased. Since there is
no increase in peripheral resistances, the
diastolic pressure remains normal; or, as
in the case of thyrotoxicosis, becomes low-
ered due to peripheral vasodilatation.

Aortic regurgitation and heart block may
cause an increase in systolic pressure
through a somewhat different mechanism.
In these two conditions there is no increase
in pulse rate. The increase in minute vol-
ume observed is due only to the increased
ventricular filling. In aortic regurgitation
the incompetent aortic valves allow the re-
flux of blood from the aorta back into the
left ventricle during diastole ; the heart
muscle fibers are stretched, react more for-
cibly (Starling’s Law of the Heart), and
systolic ejection is more complete.4 Thus
an increased diastolic ventricular volume
due to a two-way filling (mitral and aortic)
plus an increase in efficiency of cardiac
muscle results in an increased minute vol-
ume and an increase in systolic pressure.
The diastolic pressure in this condition is
obviously lowered.

Systolic hypertension associated with
heart block has a very similar pathogenesis,
the chief difference lies in the fact that
the increased diastolic ventricular volume
is due to the missing of a systolic period
rather than to valvular incompetency.

II. Hypertension Due to an Increase in
the Viscosity of the Blood : Rarely does this
factor play a prominent role in the produc-
tion of hypertension. Probably the only
clinical condition in which the hyperten-
sion could be traced to an increased viscos-
ity of the blood is polycythemia vera, the
so-called “Geisbock” form. Many claim that
in the great majority of cases exhibiting
hypertension and polycythemia, the hyper-
tension is primary and that the increased
red cell count is due to a mild cardiac de-
compensation. Tinney, Hall and Griffin,00
however, have fairly well demonstrated
that true polycythemia vera may increase
the blood pressure. They found that 40 per
cent of 163 proved cases with no demon-
strable decompensation had an associated
hypertension.

With an increase in number of red blood
cells there is an increase in viscosity of the
blood and an increase in frictional resist-
ance to flow. In the presence of an in-
creased resistance, a constant driving force,
and a constant size of the arterioles, there
must result a decrease in outflow through
the arterioles. Hemodynamical laws de-
mand that, under such conditions, the pres-
sure within the arterial tree proximal to
the arterioles must rise in order to force
enough blood through the arterioles to
equalize the arteriolar infloAV and outflow.4

This is the same mechanism whereby hy-
pertension is produced when peripheral re-
sistance is increased. The only difference
lies in the fact that in the latter, arteriolar
outflow is diminished by arteriolar con-
striction rather than by an increased fric-
tional resistance. Similarly, also, the dias-
tolic pressure is affected to a greater extent
than is the systolic.

III. Hypertension Due to a Decrease in
Elasticity of the Arterial Walls : Under this
heading there will be no attempt made to
discuss the moot relationship between

460

Sloan — Hypertension

sclerosis of the small arterioles (arterio-
sclerosis) and hypertension. Reference
will be made here only to the larger, more
elastic arteries, such as the aorta and its
immediate branches.

It is a well known fact that, during the
normal process of senescence, these vessels
undergo atheromatous and calciferous
changes; suffer a loss of elastic tissue; and
thus lose a large part of their resiliency.
As this process progresses, the large ar-
teries concomitantly become less able to
“give” with each systolic ejection of blood
from the left ventricle. The systolic blood
pressure, therefore, rises. In a similar
manner these inelastic vessels lose the
power of “clamping down” on the smaller
diastolic volume of .blood. ) The diastolic
pressure falls, remains constant, -or rises
only slightly. Patients with systolic-dias-
tolic ratios in the nature of 200/90 with
little evidence of renal damage or cardiac
enlargement, and with peripheral and fun-
dal evidence of extreme arteriosclerosis,
should exemplify this type of hypertension.

Cerebral arteriosclerosis may produce an
increase in blood pressure through the ef-
fect of cerebral ischemia on the vasomotor
regulatory centers.

IV. Hypertension Dve to an Increase in
Blood Volume : Blood volume may be in-
creased locally or generally. In either con-
dition there will be an increase in both the
systolic and diastolic pressures with a fair-
ly normal pulse pressure.

The localized increase in blood volume is
exemplified in the condition of coarctation
of the aorta."1’ Here, the mechanical over-
filling of the arteries of the upper extremi-
ties, head, and neck give rise to an increase
in blood pressure in these areas with a de-
crease in pressure distal to the constriction.

Steele and Cohn"’1 report one case of co-
arctation with a generalized hypertension
and suggest that, in some of these cases,
the hypertension may be due to renal is-
chemia. They compare the hypertension
in their case to that seen experimentally in
constriction of the renal arteries. 28

A generalized increase in circulatory vol-
ume is seen primarily with infusions4 of

hypertonic or protein-containing solutions,
and clinically in pituitary and adrenal dis-
orders. Some clinicians have obtained
good results in the treatment of patients
with essential hypertension by various
methods aimed to decrease the blood vol-
ume. Pendergrass47 noted generally a de-
crease in blood pressure in hypertensive
patients treated by irradiation of the pitui-
tary gland. He attributes this phenomenon
to the inhibition of the pituitary antidiure-
tic factor, thereby stimulating diuresis and
a decreased blood volume.

Hypertension associated with an adreno-
cortical hyperplasia20 is generally believed
to be due to the disturbance in salt and
water metabolism with a concomitant in-
crease in blood volume. Since it now seems
that Cushing’s syndrome is more frequent-
ly due to adrenocortical hyperplasia than to
a pituitary basophilic adenoma,20 herein
may lie the explanation for the high blood
pressure characteristic of this condition.

V. Hypertension Due to an Increase in
Peripheral Resistayice : Whereas the patho-
genesis of an increased blood pressure noted
in the preceding conditions and categories
is simply explained and easily understood,
it is within the present classification that
much of the confusion and mystery con-
cerning hypertension has its origin.

A great deal of experimental work has
been done on the mode of production of an
increased peripheral resistance, especially
in renal diseases and the so-called “essen-
tial” hypertension. A survey of the litera-
ture in this respect leaves one confused in
a maze of theories based upon only a few
actual facts at the present time. Suffice
it to say that early in all conditions asso-
ciated with an increased peripheral resist-
ance there is an arteriolar constriction
which may be nervous or humoral in origin.
In the presence of a constant driving force
and an increased peripheral resistance, the
pressure in the arterial system must arise
in order to maintain the necessary relation-
ship between arteriolar inflow and outflow.
Clinically this category is characterized by
an increased systolic and diastolic pressure
with a variable pulse pressure depending

Sloan — Hypertension

461

upon the relative degree of change of the
two preceding factors.

INCREASED PERIPHERAL RESISTANCE ASSOCIATED
WITH ISCHEMIA OF VITAL ORGANS

1. Brain : In any condition in which there
is an increase in the intracranial pressure,
such as in brain tumors2 or cerebral contu-
sion,1" certain physiologic mechanisms come
into play in order to preserve an adequate
cerebral arterial supply. Practically speak-
ing, the cranial cavity contains three fluids ;
that is, cerebrospinal fluid, venous blood
and arterial blood. If for any reason the
pressure within the cranium is increased,
there is a compensatory decrease in venous
blood and cerebrospinal fluid volume. The
arterial supply to the brain does not de-
crease, however, for the pressure within
the arterial tree is greater than that within
the other two systems. There is, then, ob-
viously an increase in cerebral congestion,
since the arterial supply remains constant
and the venous outflow decreases. A fur-
ther increase in intracranial pressure thus
takes place. When the intracranial pres-
sure rises above the arterial pressure, a
cerebral anemia results, with a concomitant
embarrassment to the vital regulatory cen-
ters of the brain. In order for life to exist,
the arterial pressure must rise. This rise
is brought about through a stimulation of
the medullary vasomotor centers with a re-
sulting widespread vasoconstriction.

Cerebral arteriosclerosis is another con-
dition that may produce a decrease in blood
supply to the medullary vasomotor centers
with a relative anoxemia followed by a gen-
eralized vasoconstriction. The importance
of this factor is debatable, however.

2. Kidney : For the purpose of descrip-
tion, kidney conditions associated with an
increase in blood pressure may be divided
into circulatory and excretory disorders.
Acute and chronic glomerulonephritis,05
polycystic kidneys,’2 renal artery throm-
bosis and embolism,51 kidney infarct,1’ 15
hypernephroma,48 perinephritis,45 amyloido-
sis,38 periarteritis nodosa,11 nephroptosis,40
pyelonephritis,02 and chronic mercury poi-
soning20 may be listed as circulatory. Con-
ditions associated with an obstruction to

the excretory products of the kidney may
be prostatic, ureteral or urethral in loca-
tion.10 It has been experimentally shown
(Hinman and Morrison) that the basic
fault in both circulatory and excretory le-
sions is one and the same, renal ischemia.

It is now generally believed that renal
ischemia produces hypertension through a
pressor mechanism. There are three pre-
vailing theories at the present time, and it
seems justified briefly to review each of
these.

In this country the theory of Page and
Corcoran1’ 14- 31- 12, is, 11,45, has the great_

est number of followers at the present time.
As the result of a series of experiments
over the past 10 years, they have concluded
that the primary hemodynamic fault in
renal ischemia lies in a decrease in pulse
pressure in the kidney arterioles with a
resultant relative arteriolar anoxia and an
increase in permeability of the renal vascu-
lar tree. In the normal kidney there is a
protein substance termed “renin” whose
molecule is so large that the normal kidney
vessels are impermeable to it. With the
increase in permeability resulting from the
anoxia of the vessels, this substance dif-
fuses into the blood stream. For renin to
be active as a vasoconstrictor, it must be
acted upon by a substance present in the
pseudoglobulin portion of normal plasma,
“renin activator.” The combination of ren-
in and renin activator forms a new sub-
stance termed “angiotonin,” which is the
active vasoconstrictor. It is a heat stable,
dialysable material. Normal plasma con-
tains a variable amount of inhibitor to this
reaction, called “renin-inhibitor.” In the
presence of a sufficient quantity of the lat-
ter substance, there will be no enzymic re-
action between renin and its activator.

Another inhibitory group of enzymes are
the “angiotonases.” These are antagonistic
substances, found chiefly in the kidney and
liver, which react to combat the action of
any angiotonin that may be formed.

Thus, it may be seen that the final rise
in blood pressure is dependent upon a com-
plicated series of “activator” and “inhib-
itor” type of enzymic reactions.

462

Sloan — H ypertension

A group of South American workers un-
der the leadership of Braun-Menendez7 have
arrived at similar experimental conclusions.
The greatest difference between their the-
ory and the theory of Page and Corcoran
lies in terminology.

Holz,33 in Germany, has postulated that
the normal kidney contains two chief en-
zymes which react in the metabolism of
amino-acids, decarboxylase and amino-oxi-
dase, the latter acting only in the presence
of oxygen. In conditions associated with
renal ischemia, the amino-oxidase fails to
act adequately and there is an incomplete
deaminization of amino-acids with a result-
ant formation of a number of pressor sub-
stances, phenolic compounds being the most
powerful of this group.

All of these are attractive theories, but
at the present time remain within that
realm. Suffice it to say, in conclusion, that
the actual mechanism by which renal hy-
pertension is produced remains unknown.
From recent experimental work it appears
to be humoral in nature.

HYPERTENSION DUE TO ENDOCRINE DISORDERS

Hypertension has been noted to appear
with relative frequency in the presence of
such tumors as arrhenoblastoma21 andpheo-
chromocytoma22- 23 and at the menopause.-1'
The means by which an arrhenoblastoma
produces an increase in blood pressure is
unknown; for, it is not certain as to the
type of hormone liberated by this tumor.21
It is believed to be androgenic in nature.
A polycythemia has been described accom-
panying many of these tumors (Bingel)
and could possibly be the hypertensive fac-
tor.

Pheochromocytomas increase the blood
pressure by the liberation of adrenalin.
The hypertension produced by this tumor
is characteristically paroxysmal and may
be relieved by operative removal.0

Although it has long been a noted fact
that the blood pressure of females tends to
rise during the menopause,26 so little is
known about the actual hormonal changes
at this period and the effect of these
changes upon the vascular tree, that, at the
present, it can only be said that the hyper-

tension is probably endocrine in origin. It
may, at times, be alleviated by the admin-
istration of estrogens. Its origin is, prob-
ably, closely related to the widespread sym-
pathetic imbalance characteristic of this pe-
riod of the change in life.

Adrenal cortical tumors were not includ-
ed under this heading because, although
their effect is primarily endocrine in na-
ture, the actual mechanism by which the
hypertension is produced is an increase in
blood rather than any change in peripheral
resistance. Cushing’s syndrome was omit-
ted here for a similar reason.

HYPERTENSION ASSOCIATED WITH NERVOUS
DISTURBANCES

The diencephalic syndrome of Page,43
“nervous” hypertension,54 and hypertension
associated with poliomyelitis of the brain
stem26 probably all have their origin in cen-
tral stimulation of the vasomotor centers.
The diencephalic syndrome includes a group
of patients who characteristically show
paroxysmal attacks of blushing, cold ex-
tremities, lacrymation, hyperhidrosis, der-
matographia, and hypertension. It is a
syndrome similar to that produced by ex-
perimental diencephalic stimulation. The
hypertension is primarily sympathetic in
nature as in cases exhibiting so-called
“nervous” hypertension. Individuals fall-
ing into this latter category are character-
ized by a blood-pressure that varies with
the emotional status of the patient at any
one time. It is believed that this type of
person is afflicted with a hyperirritable
nervous system which reacts more violent-
ly under emotional changes than does the
normal person. Under ordinary conditions
of living, these individuals pressure tends
to vary to a much greater extent than does
the average person’s It is probably a pre-
cursor stage to the development of essen-
tial” hypertension.54 The response to emo-
tional stimuli is probably sympathetic and
adrenergic in nature.

HYPERTENSION ASSOCIATED WITH AN INCREASE
IN BODY MASS

This heading was included because a
number of important conditions associated
with hypertension remain unclassified.

Sloan — Hypertension

463

Their only common attribute is the above;
namely, an increase in body mass.

The relationship between obesity and hy-
pertension has long been noted.39’ 50’ 53’ 60
It has been noted also, that, in rather large
series of cases, the hypertension in obese
individuals is often proportional to the de-
gree of obesity.39- 41- 60 A reduction in body
weight may result in a fall in blood pres-
sure. At times, the degree of fall is in pro-
portion to the amount of weight lost. It
seems justifiable to conclude that, in cer-
tain cases, hypertension may be precipitat-
ed by obesity.

Exactly how this is brought about is not
known. One is tempted to offer the teleo-
logic explanation that, an increase in body
mass requires some degree of increase in
pressure in order that the excess tissue may
receive an adequate amount of blood, since
there is no increase in blood volume in these
cases. It is possible that obese individuals
with an inherited hypersensitive nervous
system react to this new demand by an
excessive increase in pressure. If this
early, oftentimes transient, hypertension is
long continued, it tends irrevocably to per-
petuate itself. Loss of weight will then
have little, if any, effect upon the pressure.

Although the relationship between large
uterine fibroids and hypertension was ob-
served in the German literature years ago
with sufficient frequency to establish the
term “myoma” heart,26 very little has been
written on this subject within recent years.
That there is a relationship between these
two conditions is well recognized.66’ 10 17> 34
There have been reports of immediate and
sustained reductions in pressure following
the removal of fibroids. The manner in
which they act to produce hypertension in
certain individuals is unknown. Everett23
believes that renal ischemia, due to urinary
obstruction from extrinsic pressure of the
fibroids, explains the pressure change.

The last conditions characterized by an
increase in body mass and hypertension are
the toxemias of pregnancy. The cause is
again unknown, although it is probably en-
docrine in nature. For a toxemia to devel-
op there must be fluid retention and hyper-

tension19 much as in glomerulonephritis.
The increase in blood pressure is not on a
renal basis, however, since the renal blood
flow is normal.12’ 14 As in other conditions
associated with hypertension, the increased
pressure tends to perpetuate itself if pres-
ent for a great enough length of time. It
has been shown that the development of
permanent hypertensive vascular disease
following toxemias is dependent upon the
duration of the toxemia rather than upon
its severity.57

IDIOPATHIC OR ESSENTIAL HYPERTENSION

All remaining cases of hypertension
which do not fall into one of the previous
classifications may be termed idiopathic or
essential, and subclassed as “benign” or
“malignant” depending upon the severity
of the course and the resultant renal path-
ology. As has been emphasized before, any
hypertension that is of sufficient duration
from any cause whatsoever, or associated
with any precipitating factor such as obe-
sity, large tumors, pregnancy, and others,
may become essential or self-perpetuating
and remain after the eradication of the ini-
tiating factor.

SUMMARY

1. Emphasis has been laid on the fact
that there are many causes for the produc-
tion of hypertension and each of these con-
ditions should be considered before the
diagnosis of “essential” hypertension is
made. Many may be corrected and the hy-
pertension relieved.

2. A physiologic and clinical classifica-
tion of hypertension was presented.

3. An attempt has been made to explain
briefly the pathogenesis of hypertension in
these various disease entities.

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466

Editorials

NEW ORLEANS

M edical and Surgical Journal

Established 18hU

Published by the Louisiana State Medical Society
under the jurisdiction of the following named
Journal Committee:

Val H. Fuchs, M. D., Ex officio
For two years: G. C. Anderson, M. D., Chairman
Leon J. Menville, M. D.

For one year: J. K. Howies, M. D., Vice-Chairman
For three years: C. Grenes Cole, M. D., Secretary
E. L. Leckert, M. D.

EDITORIAL STAFF

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COLLABORATORS— COUNCILORS
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1430 Tulane Avenue

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The Journal does not hold itself responsible for
statements made by any contributor.

SENATE BILL 637

The Honorable Allen Joseph Ellender,
known to all our readers as Senator from
Louisiana, has introduced a bill in the Sen-
ate of the United States which we believe
should receive the endorsement of the
medical profession. This bill has already
been endorsed in principle by the Council
on Medical Education and Hospitals of the
American Medical Association and the As-
sociation of American Medical Colleges.

The bill has to do with “the release of

persons from active military service, and
the deferment of persons from military
service, in order to aid in making possible
the educational training of physicians and
dentists to meet essential needs.” This
briefly is the purpose of the bill which pro-
vides for the deferment from the draft of
a limited number of men who may be per-
mitted to continue their medical education.
Some of these men will come from the
armed forces, others will be young men who
have not yet been drafted but who have in-
dicated their intention of studying medicine
or dentistry. In so far as the medical stu-
dents are concerned, the number shall not
exceed 8000 who will be permitted to pur-
sue first year premedical educational train-
ing. This number is reduced for second
year training to 4500 and thereafter there
shall not be a number exceeding the 4500
in any one of the second, third or fourth
years of the medical school. The Senator
from Louisiana in this bill does not limit
the number of students who may be taken
into medical schools who are veterans of
the armed forces, women and persons not
qualified for military service. The bill is
planned to provide a sufficient number of
doctors of medicine and dentistry neces-
sary to meet essential needs of civilian pop-
ulation, especially in rural areas, and for
the armed forces in the future.

This bill seems to be well considered and
broad minded legislation. There is defi-
nitely an inadequate supply of physicians
at the present time who are engaged in
civilian practice and more particularly in
the rural regions. As pointed out in a pre-
vious editorial, the need for doctors in the
armed forces undoubtedly will continue for
a long period of time. In the meantime ac-
cretions of civilian practitioners are very
limited. The members of the medical pro-
fession now in active practice are year by
year getting older and older, consequently
either dying off or being forced to reduce
their activities. In the states of Arkansas
and Maine, for example, 25 per cent of all
practitioners have passed the age of 65.
Furthermore, there is a remarkable in-
crease in the number of physicians who

Editorials

467

wish to become specialists but a specialist
cannot go into rural practice and make a
living, he must confine his activities to the
larger centers of population. It should be
furthermore stressed that recent graduates
are tending more and more to locate in the
larger towns and cities of the country. Of
the graduates of the class of 1938 only 18
per cent remained in rural areas.

If the needs of the armed forces even
after the war will continue to be immeasur-
ably larger than they have in the past, if
so many of the young graduates wish to
engage in specialties, if the men re-enter-
ing practice do not move to rural areas,
and if a continuous supply of physicians is
not to be turned out each year by the medi-
cal schools, it is obvious that rural areas
are not going to have an adequate supply
of doctors. Senator Ellender’s bill is an
attempt to overcome the difficulties that
will have to be met to give medical care
to the people of the United States if the
continuous supply of doctors is not main-
tained. As a matter of fact if all these “if”
statements made above are valid the pro-
ponents of state medicine will have excel-
lent arguments to maintain their position
because rural areas will not have doctors
to take care of the illnesses and injuries
of the inhabitants of these more sparsely
settled districts. If for no other reason the
bill of Senator Ellender should receive the
support of our profession, the great ma-
jority of whom are opposed to state medi-
cine.

o

A PENICILLIN PROJECT

The health departments of the State of
Louisiana and City of New Orleans, with
the endorsement and cooperation of the Or-
leans Parish Medical Society, are putting
on a mass demonstration of the treatment
of gonorrhea with penicillin. Penicillin is
being provided by the two health depart-
ments in order to demonstrate first the
value of penicillin in the treatment of gon-
orrhea, and secondly in order to reach those
people who, because of pride, fear or for
economic reasons, are being self -treated or

being treated under the guidance of non-
qualified individuals.

This demonstration can hardly be called
an experiment in the treatment of gonor-
rhea because it has been definitely shown
that three doses of penicillin intramuscu-
larly given two hours apart are capable of
curing gonorrhea in 95 per cent of cases.
Two hundred thousand units of the drug
are given in divided doses in a six hour
period.

The New Orleans physicians who are
participating in this study will make the
diagnosis and will decide whether or not
the patient has been cured. The clinical
or epidemiologic diagnosis will be consid-
ered entirely satisfactory in judging the re-
sults. It will be interesting to observe and
to learn of the results of this form of treat-
ment when employed on a large scale in a
city the size of New Orleans. The physi-
cians of the city are to be congratulated on
their willingness to participate in this study
and to encourage an investigation, the re-
sult of which may turn out to be of tre-
mendous importance in the control of a
disease which, while not lethal, is produc-
tive of a tremendous amount of suffering
and unhappiness, particularly in women.
o

THE SURGICAL TREATMENT OF
HYPERTENSION

Undoubtedly many physicians have been
quizzed regarding the surgical treatment of
hypertension by their hypertensive patients
since the appearance of an article in the
Saturday Evening Post regarding sympa-
thectomy in the treatment of this disease.
Unfortunately the medical man does not
have a whole lot to offer to the patient who
has hypertension. The patient is told to
rest, to take things quietly and possibly
to take a tablet of phenobarbital two or
three times a day. Some of the patients
may do reasonably well on this regimen but
there is a tremendous number of them who
do not, as indicated by mortality statistics
which disclose the fact that a large part of
our population who die each year is now
dying from the cardiac, vascular or renal
results of continuous high blood pressure.

468

Organization Section

Smithwick,* the surgeon from the Mas-
sachusetts General Hospital who was writ-
ten up by the Saturday Evening Post, has
recently published a scientific article which
discusses the result of a ten year clinical
investigation of hypertension in man which
has been going on at the Massachusetts
General Hospital. This study has to do
largely with the role of the autonomic
nervous system and vascular disease as
mediators of hypertension. He writes that
continued diastolic hypertension is usually
seen in combination with hyperactivity of
the vascular bed, the latter preceding the
former. There is no detailed knowledge
available of the transition between the pre-
hypertensive state to the stage of persistent
diastolic hypertension. As hypertension
develops there is an increase of pulse pres-
sure with great variations in size of the
change. As hypertension improves pulse
pressure becomes smaller. It is the people
who have what he speaks of as narrow
pulse pressure type of hypertension who re-
spond best to surgical removal of a part of
the autonomic nervous system. In these in-
dividuals lumbodorsal splanchnicectomy ap-
pears to be of value. Whether this opera-
tion is going to prove ultimately to give a
certain amount of symptomatic relief over
a period of years will depend very largely
on the selection of patients. Certainly it
should not be reserved until the patient has

*Smithwick, R. H. : Some experiences with the surgical
treatment of hypertension in man, Trans. & Studies Coll.
Phys. Philadelphia, 12:93, 1944.

marked eyeground changes, marked renal
changes and in fact is just about in ex-
tremis.

o

CANCER CONTROL MONTH

April is the month designated by Act of
Congress and proclaimed by the President
as “Cancer Control Month.” The Ameri-
can Cancer Society and other organizations
are putting on special programs by radio
and are publicizing generally the impor-
tance of cancer as a cause of death in the
United States. It should be pointed out
that in Louisiana it is the second ranking
cause of death, as it is in the United States.
In the whole country there are 165,000 peo-
ple who die from this dreaded disease. It
is to be hoped that members of the State
Society will back up the efforts of those
physicians and lay people who are publiciz-
ing the necessity of early diagnosis in the
prevention of this dread and malignant
disease. In so far as we know at the pres-
ent time, cancer is curable only when de-
tected early, so that its early discovery will
depend upon such factors as yearly physi-
cal examinations of people of cancer age,
the prompt attention to bleeding from any
of the body orifices, the occurrence of indi-
gestion in a person previously free from
such symptoms, the finding of a mass in
the breast, and many other indications of
cancer which have not metastasized. With
surgery and with radiotherapy the disease
can be cured if discovered early.

ORGANIZATION SECTION

The Executive Committee dedicates this page to the members of the Louisiana
State Medical Society, feeling that a proper discussion of salient issues will contri-
bute to the understanding and fortification of our Society.

An informed profession should be a wise one.

VALUABLE MEDICAL TOPICS
We wish to make a report of the results
of the various medical surveys which we
have sent out to the membership in the
state in order to obtain information which
will be of help to physicians returning from
military service. We were very gratified
with the results obtained on the postcards,

from which was obtained information as to
the needs of different parishes and cities
for medical men. This will be of value to
the doctors, when they are discharged, as
a guide to suitable locations and needs for
same in the state.

We have not yet received replies from

Organization Section

469

forty-six parishes on the questionnaire sent
to them on request of the Bureau of Infor-
mation, Chicago. We urgently ask that you
complete the data as rapidly as possible and
return to our office, as it is necessary for
us to rearrange, make additions, and sup-
ply other information before returning
same to headquarters in Chicago. All of
this material gathered by these surveys will
be reviewed by our Committee on Postwar
Planning with the object of recommending
adequate post-graduate medical education
and assisting in helping the physicians to
re-establish themselves in practice upon
their return. In order to complete this
work we must have your cooperation in get-
ting these data into our office. Most of the
answers which we have received from the
men in service seem to indicate a distinct
desire to return to their old locations, prob-
ably needing a few weeks or a month of
post-graduate work. They are trusting also
to find everything just as it was before
they entered the service.

There is at present a tremendous fight
being waged on the medical facilities of the
United States Veterans’ Bureau. The pub-
lic is interested in this subject and I would
like to refer you to the March issue of the
Cosmopolitan where there is a very inter-
esting article entitled “Third-rate Medicine
for First-rate Men” by Albert Q. Maisel.
This is a very interesting discourse on the
inadequate medical facilities of the Veter-
ans’ Hospitals with special reference to
tuberculosis, mental diseases, and over-
crowding of the institutions. Congress is
also investigating veterans’ facilities. The
fourth interim report of the Subcommittee
on Wartime Health and Education is de-
voted entirely to the health needs of veter-
ans. Senator Claude Pepper, Chairman of
this subcommittee, makes the following
statements : “Every possible step must be
taken to make certain that good medical
care is within the reach of every veteran,”
the report maintains, and although the com-
mittee says that' “its first consideration is
the care of those disabled as a result of
military service,” its proposals indicate

great concern over medical care for all vet-
erans regardless of whether or not their
disabilities are service connected.

“Criticisms of the quality of service giv-
en by the Veterans’ Administration have
been made to the subcommittee by organi-
zations and individuals who speak authori-
tatively. It has been stated that the medi-
cal care of veterans does not measure up
to the best standards.

“So important to the Nation is the assur-
ance of good medical care for veterans that
the subcommittee proposes to ascertain the
facts about the quality of medical care in
the Veterans’ Administration. It will make
a study of the present medical care pro-
gram and of plans to meet the heavy re-
sponsibility with which the Veterans’ Ad-
ministration will be faced in the future.
This study will be made at once with the
help of outstanding authorities in various
medical specialties, veterans’ organizations,
and professional groups.”

Anyone can obtain a copy of this report
by writing to his senator or representative.
Special emphasis is being placed on the vet-
erans’ investigation due to the fact that a
great many of the casualties are being re-
turned to the United States and need hos-
pital and medical care through the Veter-
ans’ Bureau. Such service the bureau seems
to be entirely unable to supply. Many,
many more hearings are expected before
Senator Pepper and his committee may be
ready to recommend legislation. It is be-
lieved that this committee is really attempt-
ing to obtain the best possible medical opin-
ion before making final recommendations.

You should watch the developments of
Senate bill 191 known as the Hill-Burton
bill, authorizing a national survey of
health facilities and providing for the con-
struction of hospitals. This would indicate
that it may be possible to arrange for ade-
quate medical care by appropriate legisla-
tion with state levels without depending
upon the supervision of the United States
Public Health Service or other agencies.
Hearings on this bill began on February
26, at which time the medical profession

470

Orleans Parish Medical Society

was represented by a member of the Board
of Trustees of the American Medical As-
sociation and by the Secretary of the Coun-
cil on Medical Education and Hospitals.
Anyone interested in reading the testimony
and editorials on this important bill should
see pages 652 and 656 of the Journal of
the American Medical Association, March
17, 1945. It is very interesting to note
that this bill is endorsed in principle by
the American Medical Association and is
sponsored by the American Hospital As-
sociation. The general opinion is that this
is the first real scientific approach by
means of national legislation toward the
problem of distribution cf medical care
where the need can he shown. The signifi-
cant point in this bill is that the control is
left in the hands of local communities.

Recent reports would indicate that Sena-
tor Wagner is proposing to revamp his for-
mer Senate bill 1161 which was introduced
in the 78th Congress. These changes would
indicate that he anticipates meeting the
chief objections that had been raised to the
old Wagner bill. The changes call for :
First, the selection of the physician and the
maintenance of the relationship between
physician and patient; second, it will be
regulated by an Advisory Council instead
of by the Surgeon General of the United
States Public Health Service; third, it will
call for lower tax rate. He evidently an-
ticipates having this introduced very short-
ly, which will require serious study by the
medical profession as to his implications
and whether it would be antagonistic to
the American way of practicing medicine.

Senator Ellender of Louisiana has intro-
duced Senate bill 637, which provides for

the deferment of premedical and predental
students. The bill was drafted after con-
sultation with the Council on Medical Edu-
cation and Hospitals of the American Med-
ical Association and the Executive Council
of Association of American Medical Col-
leges. (See Journal of American Medical
Association, March 10, pages 592 and 599.)
This attempts to correct the current dras-
tic regulations which resulted in a restric-
tion in the number of students qualified to
enter courses of medical instruction in ap-
proved medical schools. This bill, if passed,
will relieve our apprehensions concerning
the providing of adequate medical men for
future civilian use.

In regard to voluntary prepayment medi-
cal insurance, which is of interest to our
medical societies, you should know that re-
cently four more states have provided for
a prepayment voluntary medical insurance
plan, namely, Iowa, Ohio, Connecticut, and
Indiana.

The American College of Radiology has
called our attention to the critical shortage
of radiographic film similar to the short-
age which occurred two years ago. This is
due to the increased demands of the Army
and Navy. They ask that every economy
be practiced and that conservation of sup-
plies now on hand be made until produc-
tion catches up with demand. Hospital
staffs should limit and forego the ordering
of routine roentgenologic examinations, re-
questing x-ray studies only for cases where
clinical findings warrant such procedure.
It is very timely that this request be com-
plied with in order that adequate supplies
of radiographic film may be had for those
who urgently need same.

CALENDAR OF MEETINGS
April 2 Board of Directors, Orleans Parish
Medical Society, 8 p. m.

April 3 Eye, Ear, Nose and Throat Staff, 8
p. m.

April 4 Mercy Hospital Staff, 8 p. m.

Executive Committee, Baptist Hospital,
8 p. m.

April 9 Scientific Meeting, Orleans Parish
Medical Society, 8 p. m.

April 11 Woman’s Auxiliary, Orleans Parish
Medical Society, Orleans Club, 3
p. m.

TRANSACTIONS OF ORLEANS PARISH MEDICAL SOCIETY

April 5

Orleans Parish Medical Society

471

April 12

April 16
April 17
April 18
April 20
April 24
April 25

April 26

April 27

Clinico-pathologic Conference, Marine
Hospital, 7 :30 p. m.

Touro Infirmary Staff, 8 p. m.
Clinico-pathologic Conference, Touro
Infirmary, 12 noon.

Hotel Dieu Staff, 8 p. m.

Charity Hospital Medical Staff, 8 p. m.
Charity Hospital Surgical Staff, 8 p. m.
I. C. R. R. Hospital Staff, 12:30 p. m.
Baptist Hospital Staff, 8 p. m.
Clinico-pathologic Conference, Marine
Hospital, 7 :30 p. m.

Catholic Physicians’ Guild, 8 p. m.
French Hospital Staff, 8 p. m.
Clinico-pathologic Conference, Touro
Infirmary, 12 noon.

DePaul Sanitarium Staff, 8 p. m.

L. S. U. Faculty, 8 p. m.

New Orleans Hospital Dispensary for
Women and Children Staff, 8 p. m.

HOSPITAL NEWS

During the month of March the Society held
one scientific meeting. The program was as fol-
lows: Comparison of Incidence and Treatment of
Meningitis Over a Ten-Year Period by Drs. John
H. Musser and Harry E. Rollings; A Simple
Treatment for Sebaceous Cyst, by Dr. Joseph A.
Danna.

At a recent meeting of the Tulane University
History of Medicine Society, Dr. Hiram W. Kost-
mayer was presented with a valuable pigskin-
bound reproduction of Vesalius’ Anatomy of the
Human Body. Dr. B. Bernard Weinstein made
the presentation. Dr. Alton Ochsner was the
guest speaker for the society’s meeting; his sub-
ject being, “The History of Thoracic Surgery.”

Dr. Sam Nelken spoke on “The Social Develop-
ment of Children and Children in War” at a
recent meeting of the Isidore Newman Parent-
Teachers’ Association.

Dr. R. C. Voss was recently advanced to the
position of associate medical director of the Pan-
American Life Insurance Company of New Or-
leans.

Dr. Edgar Hull and Dr. Louis Monte recently
attended the regional meeting of the American
College of Physicians in Memphis. Dr. Hull, who
is College Governor for Louisiana, presented a
paper titled, “Bacterial Endocarditis.”

At a recent meeting of the New Orleans So-
ciety of Neurology and Psychiatry, Dr. Theo A.
Watters was elected president; Dr. Sam Nelken
was elected secretary.

NEWS ITEMS

Dr. John S. LaDue, Dr. Louis Levy, II., and
Dr. Reynold Patzer attended the regional meet-
ing of the American Federation for Clinical Re-
search in Dallas, February 2-3. Dr. LaDue read
a paper on “Possible Explanation of the Mechan-
ism of Compensation of the Failing Human
Heart;” Dr. Levy read a paper concerning “Re-
sults in the Treatment of Subacute Bacterial En-
docarditis Employing Combined Penicillin and
Heparin Therapy;” and Dr. Patzer read a paper,
prepared by himself, Dr. Vincent Derbes and Dr.
Hugo Engelhardt, on “Periarterial Infiltration in
the Diagnosis and Treatment of Migraine — Ex-
perimental and Clinical Experiences with Eucu-
pine and Procaine.”

Dr. Guy A. Caldwell attended a meeting of the
Advisory Board of Medical Specialists in Chicago,
February 10-11.

Dr. Lewis E. Jarrett spoke on Socialized Trends
at a meeting of the New Orleans Dietetic Asso-
ciation held February 6 at Charity Hospital.

At a recent meeting of the L. S. U. Faculty
Club, Dr. R. E. Arnell spoke on Eclampsia — A
Six-Year Study.

Dr. Alton Ochsner recently spoke before vari-
ous medical societies in Merida, Mexico, and in
cities in Guatemala, Costa Rica and Panama.

At the January monthly meeting of the Medical
Staff of DePaul Sanitarium the following officers
were installed for the year 1945: Dr. Edmund
Connely, president; Dr. T. A. Watters, vice-presi-
dent, and Dr. Louis J. Dubos, secretary-treasurer.

Major Hardee Bethea and Captain John S. Her-
ring, both stationed in the Pacific area were home
on leave recently.

Lt. Richard Corales, Jr., is now stationed at
the U. S. Naval Hospital in New Orleans.

Lt. Jack C. McCurdy received the Navy Cross
“for extraordinary heroism in action” against the
enemy on Guam, July 21, 1944, while serving as
battalion surgeon with the United States Marines.
Rear Admiral A. C. Bennett, U. S. N., comman-
dant of the Eighth Naval District, made the
presentation at ceremonies held February 8 at
the Houma Naval Air Station. Before entering
the service, Lt. McCurdy was a resident at Baptist
Hospital.

It has been reported that Major C. Barrett
Kennedy is ill and confined to a hospital in Italy.

DE PAUL SANITARIUM STAFF MEETING
The following report was received from Dr.
Louis J. Dubos, Secretary:

The Regular Monthly Meeting of the Medical

472

Louisiana State Medical Society News

Staff of De Paul Sanitarium was preceded by
the annual dinner, and called to order at 8:55
p. m., with Drs. Fuchs, Cole, Thompson, H. Co-
lomb, A. Colomb, May, Otis, Holbrook, Anderson,
Watters, Blum, Graffagnino, Friedrichs, Golden,
O’Hara, Connely and Dubos in attendance.

There was no presentation of cases at this
meeting, so Dr. Otis summarized in detail the
reports of the various departments for the entire
year of 1944, all of which showed satisfactory
progress.

When requested by the Chairman to say a few
words, Sister Anne expressed her sincere appre-
ciation of the work of the members of the Staff
during the past year and their hearty co-opera-
tion in meeting and maintaining the approval of
the American College of Surgeons and thereby
placing De Paul Sanitarium on the “approved list”
of hospitals where it justly belongs.

In reviewing the progress of promoting psy-
chiatric nursing, Sister Anne said that the pro-
gram of 1944 had not been as successful as the
program of 1943 and had failed to achieve its goal
— that of establishing a School of Psychiatric
Nursing. Such a school would of necessity have
to be set up on the same level as the other Schools
of Nursing in New Orleans — that is, on a uni-
versity level, particularly if the students of
Charity Hospital were to come into it, since they

have a university affiliation. Sister Henrietta
concurred in this opinion, suggesting that Charity
Hospital nurses be sent up to De Paul Sanitarium
for practical training, management, teaching and
field practice if such a permanent course could
be arranged.

A motion was made by Dr. Friedrichs and
seconded by Dr. Holbrook that a committee be
appointed to write a letter of appeal to the
Mother Provincial of the Sisters of Charity in St.
Louis, requesting her assistance in establishing
such a school by sending a Sister to De Paul
Sanitarium for the definite purpose of organiz-
ing a nursing school program.

Dr. Golden stated that he hoped that residencies
in neuropsychiatry would eventually be estab-
lished at De Paul Sanitarium as well as the other
general hospitals in the city because up to the
present time no specialized neuropsychiatrist has
ever been trained here in New Orleans.

Sister Anne informed the entire Staff that she
had acquired the services of an excellent occupa-
tional therapist whose services would be available
daily.

There being no further business, the meeting
was adjourned at 9:50 p. m., followed by a meet-
ing of the New Orleans Society of Neurology
and Psychiatry.

■a

LOUISIANA STATE MEDICAL SOCIETY NEWS

Society

East Baton Rouge

Morehouse

Orleans

Ouachita

Rapides

Sabine

Second District

Shreveport

Vernon

CALENDAR

PARISH AND DISTRICT MEDICAL SOCIETY

Date

Second Wednesday of every month
Second Tuesday of every month
Second Monday of every month
First Thursday of every month
First Monday of every month
First Wednesday of every month
Third Thursday of every month
First Tuesday of every month
First Thursday of every month

MEETINGS

Place

Baton Rouge
Bastrop
New Orleans
Monroe
Alexandria

Shreveport

EAST AND WEST FELICIANA BI-PARISH
MEDICAL SOCIETY

After an excellent dinner in the East Louisiana
State Hospital dining room, the society repaired
to the Staff Room for a scientific program.

Electric shocks were given to several patients,
and presentation of cases on constitutional psy-
chopathic personality, paranoid dementia precox
simple type, psychoneurosis and paresis.

The program, which was enjoyed by all pres-
ent, was presented by Drs. Strum, Green, Nolan
and Robards.

Dr. Toups of Baton Roue, Louisiana, was elect-
ed honorary member of our society.

A vote of thanks was extended to Dr. Glenn
J. Smith, and staff, for their entertainment.

Society adjourned to meet the first Wednes-
day of June, 1945.

B. F. Smith, President
E. M. Toler, Secretary.

o

RAPIDES PARISH MEDICAL SOCIETY

At a recent meeting of the Rapides Parish
Medical Society the following officers were elect-
ed for 1945: President, Dr. H. H. Hardy, Jr.,
Alexandria; First Vice-President, Dr. F. A.
Thomas, Urania; Second Vice-President, Dr. Ed-

Louisiana State Medical Society News

473

mond Klamke, Alexandria; Secretary-Treasurer,
Dr. R. U. Parrott.

o

ACADIA PARISH MEDICAL SOCIETY
The following officers were elected at the
meeting of the Acadia Parish Medical Society held
in Crowley on February 21: President, Dr. U. J.
Arretteig, Church Point; Vice-President, Dr. G.
G. Fontenot, Morse; Secretary-Treasurer, Dr. A.
A. Williams, Church Point.

o

IBERIA PARISH MEDICAL SOCIETY
At a recent meeting of the Iberia Parish Med-
ical Society the following officers for 1945 were
elected: President, Dr. Henry J. Dauterive; Vice-
President, Dr. Harold M. Flory; Secretary-Treas-
urer, Dr. P. M. Payne; Delegate, Dr. W. P. D.
Tilly, all of New Iberia.

o

NEWS ITEMS

Dr. G. W. McCoy, Professor and Director,
Department of Public Health, Louisiana State
University School of Medicine, attended the Na-
tional Foundation for Infantile Paralysis meeting
in New York City, March 13-14, and a meeting
of the U. S. Pharmacopoeial Revision Commit-
tee in Washington, D. C., March 16, 1945.

The American College of Chest Physicians has
cancelled its 11th Annual Meeting, which was
to have been held in Philadelphia, June 16-19.

The American Psychiatric Association, the old-
est Medical Society in America, has announced
the cancellation of their 101st Annual Meeting,
which was to have been held in Chicago, in May
of this year. It was the feeling of the Associa-
tion that it would be the duty of the membership
to fall in line with the request of the United
States Government to cancel conventions in the
spirit of the war cooperation.

The annual banquet of the Southern Baptist
Hospital Staff was held at the Jung Hotel Roof,
March 27, at 8 p. m.

The general oral and pathological examinations
of the American Board of Obstetrics and Gyne-
cology will be conducted in Atlantic City, June
14-19. The Hotel Shelburne will be the head-
quarters for the board.

o

ARMY MEDICAL RESEARCH BOARD
Lieutenant Colonel Roy H. Turner, M. C., Chief,
Communicable Disease Treatment Branch, Med-
ical Division, Surgeon General’s Office, has been
placed on the Executive Committee of the Army
Medical Research Board, of which Major General
George F. Lull, Deputy Surgeon General, is
President. Brigadier General Stanhope Bayne-

Jones, a former New Orleanian, is also on this
Executive Committee. Also on the committee of
eight is Lieutenant Colonel Michael E. DeBakey,
Chief, General Surgery Branch, Surgical Division
of the Surgeon General’s Office.

• o

POSTGRADUATE COURSE IN MEDICINE
A postgraduate course in “Recent Advances in
Therapy’’ was held under the auspices of the
Department of Graduate Medicine of the Tulane
University of Louisiana School of Medicine,
March 5-10. This course was under the direction
of Dean Kostmayer, with Professor George Burch
in charge of arrangements. The course was at-
tended by 61 men, five from Central America,
with representatives from seventeen states. Five
of the attendants came from the state of Mich-
igan, three from Illinois, one from South Dakota,
as well as from practically every state south of
the Mason-Dixon line.

The program was participated in by members
of the faculty of the School of Medicine, with two
guest speakers, Dr. Raymond Gregory, Professor
of Medicine at the University of Texas School
of Medicine, and Dr. Irving H. Page, Director
of Research at Cleveland Clinic, Cleveland, Ohio.
o

HEADQUARTERS, EUROPEAN THEATRE OF
OPERATIONS, U. S. ARMY
Award of the Bronze Star Medal to Capt. S.
E. Morgan of New Orleans, La., has been an-
nounced by the 101st Airborne Division.

Learning of several wounded soldiers badly in
need of medical care, Capt. Morgan braved heavy
enemy mortar and small arms fire to reach the
forward position in which they were. When
enemy attacks forced other men of the position
to withdraw, Capt. Morgan supervised the evacua-
tion of less seriously injured, and elected to re-
main with those casualties who were too danger-
ously injured to be moved, despite the risk of
capture or death.

o

ALPHA OMEGA ALPHA
The annual banquet preceding the induction of
new members into the Stars and Bars Chapter
of Alpha Omega Alpha medical honorary fra-
ternity was held at the Hotel Jung on Monday,
March 19. In addition to the old members and
the initiates, the three officers of Alpha Omega
Alpha chapter at Louisiana State University
Medical Center were guests. Dr. Joseph Menen-
dez acted as toastmaster and the toast of the
evening was delivered by Dr. Alfred E. Cohn,
Member Emeritus of the Rockefeller Institute for
Medical Research.

On the following night Dr. Cohn spoke on
“Disease of the Heart” at a public meeting. Suc-
ceeding this talk the members of the Senior class
at Tulane elected to A. 0. A. were inducted into
membership. They were: Thomas G. Baffes,

474

Louisiana State Medical Society News

Rodney C. Jung, John J. Baehr, William D.
Franklin, William H. Blahd, Beverly Blood, Ger-
ald N. Weiss, Gerald S. Berenson, Roy White,
Jr., George W. Prather and Merrill S. Prows.
o

ARMY ACHIEVING SPEEDY EXPANSION
OF HOSPITALS

The Army’s expansion of its general hospitals
by 70,000 beds is being rapidly accomplished
through the conversion of existing buildings on
hospital grounds rather than through new con-
struction, according to the Office of The Surgeon
General.

“At many of the general hospitals,” said Briga-
dier General Raymond W. Bliss, U. S. A., Assist-
ant Surgeon General, “there are well-constructed
barracks, built with an eye to the future, which
were used to house overseas hospital units dur-
ing their training period. These barracks are
now being turned into wards for patients. Per-
manent barracks, built to house the hospital staff,
are also being converted into wards and are be-
ing replaced with temporary barracks which can
be quickly constructed.”

Over 50,000 more patients are being cared for
in the Army’s general hospitals than was the case
three months ago. During the past month about
1,200 casualties arrived from overseas daily.

o

MASS CHEST SURVEYS

The American College of Radiology announces
that their policy in regard to mass chest surveys
is as follows:

“The American College of Radiology approves
the principle of mass chest surveys for the de-
tection of pulmonary tuberculosis for public
health purposes.

“The films should be examined by physicians
who are trained and competent to interpret radio-
graphs of the chest.

“Cases showing abnormalities should be imme-
diately referred for further study and care to
local physicians, or, when this is impractical, to
other available agencies.

“In case-finding surveys conducted as a public
health measure by eleemosynary agencies, the
fee for roentgen interpretation of survey films
should be a sum approximately equal to fifteen
dollars per hour, said fee to be a matter of agree-
ment among radiologists in the area concerned.”

These releases were reaffirmed at the meeting
held September 27, 1944, in a conference with
Dr. Herman S. Hilleboe, Director of the Division
of Tuberculosis Control of the United States
Public Health Service.

o

INFECTIOUS DISEASES IN LOUISIANA

The morbidity report of the Louisiana State
Department of Health showed that for the week
ending February 10 the following diseases were
reported in numbers greater than 10: Measles

35, malaria 31, chickenpox 28, unclassified pneu-
monia 25, scarlet fever 18, pulmonary tubercu-
losis 17, mumps 15, diphtheria 11. It is rather
unusual to have as many as 10 cases of diphtheria
reported. This week six of these cases came
from Vermilion Parish. Most of the cases of
malaria were reported from military sources; as
a matter of fact, 28 were contracted outside the
Continental United States. For the week which
ended February 17, chickenpox was first in the
number of cases listed by the State Board of
Health. There were 65 cases followed by 48 of
malaria, 31 of whooping cough, 28 of unclassified
pneumonia, 26 of pulmonary tuberculosis, 24 of
measles, 17 of scarlet fever, and 16 of dysentery.
The diphtheria cases were scattered over the
whole state. Of the malaria cases, 46 were con-
tracted outside of the Continental United States.
P^or the following week, February 24, malaria
again was very high with 32 cases, and 28 of
them were from military sources. Of the purely
local diseases there were 35 cases of tuberculosis,
25 of chickenpox, 21 of unclassified pneumonia,
20 of scarlet fever, 19 of measles, and 18 of
mumps. No unusual or rare diseases have been
reported during the month of February. The
morbidity report for the week ending March 3
contains the monthly statistics of the venereal
diseases. In that period of time there were 1,420
cases of gonorrhea listed, 1,145 of syphilis,
granuloma inguinale 31, 21 of chancroid, and
12 of lymphopathia venereum. There are two re-
markable features of this report aside from the
large number of venereal disease cases that were
reported, namely, that 151 cases of cancer are
listed, and 153 of unclassified pneumonia. This
was decidedly a pneumonia as well as a venereal
disease report because there were listed also 48
cases of pneumococcic pneumonia. All these
pneumonia cases came from the civilian popula-
tion except one. Other diseases reported in num-
bers greater than 10 include 67 cases of pul-
monary tuberculosis, 52 of chickenpox, malaria
41, rheumatic fever 34, septic sore throat 17,
scarlet fever 16, measles 15 and mumps 14.

o

HEALTH IN NEW ORLEANS
The Bureau of the Census, Department of
Commerce, reported that during the week end-
ing February 10 there were 165 deaths in the
City of New Orleans as contrasted with 152 of
the previous week. Ninety-eight of the deaths
were in the white and 67 in the colored popula-
tion, with nine of the deaths occurring in children
under one. The following week the figures were
very close to those of the previous week. Of
the 159 deaths taking place in the city, 107 were
white, 52 non-white, with 11 deaths in small chil-
dren. For the week closing February 24, 151
people expired in the City of New Orleans. The
number of white deaths dropped to 86 and the

Louisiana State Medical Society News

475

non-white increased to 62. Thirteen of those who
died were small children, mostly colored. For the
week which ended March 3 there were 141 deaths,
divided 90 white, 50 non-white, with a very con-
siderable number of the total deaths being chil-
dren. This time the infant mortality was high
among the white children with 12 of them expir-
ing and only five in the colored population. For
the week which closed on March 10 there was
a decided improvement in the number of deaths,
only 113 being reported, separated by races, 70
white, 43 colored. There were 11 children under
one year of age dying this week.

DR. RALPH HOPKINS
(1876-1945)

One of the outstanding medical men of New
Orleans passed away on the seventh of March.
Dr. Ralph Hopkins was known not only as a splen-
did dermatologist but he undoubtedly was the
outstanding authority on leprosy in this country.
For forty-three years he had been associated with
the United States National Leprosarium at Car-
ville. It was said of Dr. Hopkins that except
when he served in France in the last war that
in this period of time he had not missed more than
three or four weekly visits to the institution.

Dr. Hopkins was professor of dermatology at
Tulane for many years. He was vice-president at
the time of his death of the American Dermatolog-
ical Association.

A kindly man, skilled in his profession, he was
universally liked and respected. It was said of
Hopkins that he had no enemies.

DR. HENRY AUSTIN MACHECA
(1896-1945)

The many friends of Dr. Henry A. Macheca
heard with sorrow of his death Monday, March 19,
following a heart attack. On account of ill health
Dr. Macheca retired from active practice five
years ago. Prior to that time he served on the
staffs of Touro and Charity Hospital, and had
taught at the two medical schools in New Or-
leans. He has been a member of the Orleans
Parish and the State Medical Societies for many
years, as well as being a member of the Amer-
ican College of Surgeons and the Phi Chi Medical
fraternity.

o

WOMAN’S AUXILIARY

REPORT OF THE WOMAN’S AUXILIARY TO
THE LOUISIANA STATE MEDICAL
ASSOCIATION F.OR MARCH 1945
News from the Woman’s Auxiliary this month
brings activity in scope both national and local.
Busy Mrs. Rhodes Spedale, as president, went to
Chicago to attend a conference of State Presi-

dents, Presidents-Elect, and Chairmen of Stand-
ing Committees of the Women’s Auxiliary to the
American Medical Association. The mid-year
meeting of the State Auxiliary Board was held at
the home of the president in Plaquemine, and a
majority of the parish groups have been visited
by her.

The purpose of the national conference at this
time was to promote the exchange of ideas of mu-
tual interest and help to state auxiliaries. Al-
though state programs must follow the national
outline in general, plans and problems which arise
in local groups are of cumulative value when dis-
cussed with others.

Mrs. John P. Helmick, whose charm and per-
sonality will be remembered from her visit at the
time of the auxiliary convention last spring, pre-
sented greetings to the group fi’om the Woman’s
Auxiliary to the Southern Medical Association.
Mrs. David W. Thomas, president of the Woman’s
Auxiliary to the American Medical Association,
directed the activities of the conference. Mrs.
Jesse D. Hamer, of Arizona, was introduced to
the group as president-elect of the national aux-
iliary.

The following were elected as officers of the
meetings: Mrs. Roscoe Meisman, Washington, Con-
ference Chairman; Mrs. Lee J. Schaefer, Kansas,
Secretary; and Mrs. Fidler, Ohio, Chairman of
the Committee on Recommendations.

Contact of the state group with the Woman’s
Auxiliary to the Southern Medical Association was
furthered through a visit of Mrs. W. W. Potter,
president-elect of the latter organization, to New
Orleans, as guest of Mrs. Paul Lacroix, where she
was also met by Mrs. Spedale.

Shreveport, Ouachita, Rapides, East Baton
Rouge, and Lafourche Auxiliaries have been on
the travel itinerary of the Louisiana president.
Vermilion and Acadia parishes have been reor-
ganized! They are enthusiastically welcomed into
the parent organization.

All parishes are further urged to “disseminate
information and educational material regarding
the Wagner, Murray-Dingell bill” and copies of
said bill have been mailed to every state officer,
chairmen of standing committees, and parish pres-
idents.

April has been designated as Cancer Control
Month, and every doctor’s wife is expected to
take an active part in the campaign. Mrs. H. A.
Thompson, State Commander of the Women’s
Field Army, has cited several auxiliary members
for the valuable time they have given to this
worthy cause. A still higher goal for alleviation
of needless suffering and death is the aim of
the coming drive.

The celebration of the Foux'th Anniversary of
the U. S. O. was made complete with auxiliary
representation through Mrs. Paul Lacroix, presi-
dent-elect.

476

Louisiana State Medical Society News

In addition to the many phases of war parti-
cipation, doctors’ wives should work unitedly as
never before in promoting health education, pub-
lic relations, in fighting tuberculosis, and in com-
memoration of Doctors’ Day on March 30. Edi-
tors of the New Orleans newspapers have prom-
ised cooperation in the latter activity with car-
toons and editorials on that date, and parish
chairmen are in a position to suggest similar pub-
licity with ideas concerning present projects of
their groups.

Upon recommendation of Mrs. Spedale, the
president elect of the association will hereinafter
be also the chairman of organization. This
chairmanship will enable her to have Closer con-
tact with the auxiliary members before taking
office. She will not only be in a position to or-
ganize new auxiliaries, but to contact members
of disbanded groups, and to encourage the active
societies to a more progressive status.

It is with extreme regret that notice must be
given of the plans for a Louisiana State Medical
Meeting this year. It was at first thought that
a business meeting of the auxiliary might be per-
mitted at the same time as the one day session
of the House of Delegates of the doctors’ group,
but it is now definite that neither will be pos-
sible this year.

It is therefore at the special request of Mrs.
Spedale that minutes of the Board meeting are
being printed as recorded so that those absent
will know exactly what took place. A careful
perusal of $ie agenda is urged of all members.
Parish presidents and chairmen of publicity are
cordially invited to send material of interest to
the group to the state chairman for inclusion in
these monthly reports.

Respectfully submitted,

(Mrs. Edwin R.) Mazie Adkins Guidry,

Chairman of Press and Publicity.

o

EXECUTIVE BOARD MEETING

February 6, 1945.

A meeting of the Executive Board of the
Woman’s Auxiliary to the Louisiana State Medical
Society was held on February 6, 1945, at the
home of the President, Mrs. Rhodes J. Spedale,
in Plaquemine, La.

Mrs. Spedale called the meeting to order and
the assembly rose to unite in saying the Lord’s
Prayer.

The secretary called the roll of officers, chair-
men of standing committees, and parish presi-
dents. The following members were present:

Mesdames Rhodes Spedale, Paul LaCroix, Ar-
thur Long, Carroll Gelbke, R. D. Martinez, Frank
Jones, E. C. Melton, Kelly Stone, M. C. Wiginton,
John S. Dunn, C. Grenes Cole, Daniel Murphy,
J. E. Heard, Roy B. Harrison, Roy C. Young,

Theodore Simon, Wiley A. Dial, Aynaud Hebert
and Lloyd Kuhn.

Mrs. Spedale introduced Mrs. Paul LaCroix,
President-Elect, and announced that Mrs. La-
Croix had represented the State Auxiliary at the
celebration of the U.S.O. Fourth Anniversary,
and that she had also entertained Mrs. W. W.
Potter, President-Elect of the Southern Medical
Auxiliary.

The minutes of the Post-Convention Board
meeting were read. Mrs. Murphy asked that the
phrase “Study of the Wagner-Murray-Dingell
Bill” be changed to “Opposition to the Wagner-
Murray-Dingell Bill,” in the outline for the pro-
gram for 1945. With this correction the minu-
tes stood approved.

Mrs. R. D. Martinez, Treasurer, presented the
treasurer’s report with a balance of $385.22. This
report was filed with the consent of the assembly.

Mrs. Arthur Long, Vice-President, took the
chair while the President gave her report. Mrs.
Spedale reviewed the work done by the auxiliary
to date in 1944-45. She urged all Parish Auxil-
iaries to remain organized even if it is necessary
to be inactive due to decreased membership.
Eighteen parish auxiliaries were reported as ac-
tive this year. Mrs. Spedale reported that she
attended the A.M.A. Convention in Chicago, and
that Mrs. Cole, Mrs. Harrison, Mrs. Peacock, Mrs.
Donovan Browne and Mrs. Herald attended also.
Mrs. Herald was made Constitutional Secretary at
that time. Mrs. Spedale and Mrs, Herald also at-
tended the Fall Conference. In conclusion Mrs.
Spedale made the following recommendation:
“that the President-Elect be made Chair-
man of Organization. This chairmanship
will enable her to have closer contact
with Auxiliary members before taking
office. In order to reap any benefit
from said chairmanship she must be ac-
tive, not only in organizing new auxiliar-
ies, but in contacting auxiliaries that
have disbanded and encouraging the ac-
tive ones to a more progressive status.”

Mrs. LaCroix moved, seconded by Mrs. Cole,
that the recommendation be accepted. Motion
passed unanimously. The President’s report was
placed on file.

Mrs. E. C. Molton, Corresponding Secretary,
reported 72 cards and letters written, and 35
copies of the Wagner-Murray-Dingell Bill mailed
to Parish Presidents and officers of the Aux-
iliary.

Councilors’ Reports

Mrs. Theodore Simon, First District Councilor,
reported that district fully organized and func-
tioning satisfactory.

Mrs. Roy B. Harrison, Second District Council-
or reported the reorganization of that district
with nine members. The new officers were elect-
ed as follows: Mrs. John Atkinson, Gretna, Pres-

Book Revieivs

477

ident; Mrs. William Guillotte, Vice-President;
Mrs. Earl Clayton, Recording Secretary; Mrs. P.
A. Donaldson, Treasurer.

Mrs. Spedale commended the work of the Sec-
ond District.

These reports were placed on file.

Reports of Chairmen of Standing Committees

Mrs. Lloyd Kuhn, Chairman Cancer Control,
reported that she attended the first meeting of
the state committee and announced that materials
and letters will be sent to each parish auxiliary.

In the absence of Mrs. Taquino, Chairman of
Doctors’ Day, Mrs. Spedale reported that letters
have been sent to each parish auxiliary asking for
reports concerning their plans for Doctors’ Day.

Mrs. Wiginton, Fiance Chairman, read the bud-
get for the year.

Mrs. John S. Dunn, Historian, reported that
letters have been sent to each parish president
asking for pertinent illustrations and articles.

Mrs. Aynaud Hebert, Chairman of Indigent
Widows’ Fund, reported one donation from Iber-
ville Auxiliary and three personal donations mak-
ing a total of $36.00.

Mrs. C. Grenes Cole, Chairman of Legislatoin,
reported on the work in opposition to legislation
regarding socialized medicine.

Mrs. David Murphy, Chairman of Printing, re-
ported that the Year Book supplements and the
stationery had been printed within the budget
allowed.

Mrs. Heard, Chairman of Public Relations, re-
quested that we publicize the radio proram en-
titled “Doctors Look Ahead.”

Mrs. Young, Chairman of Revision of By-Laws,
stated that the revision of the A.M.A. Constitu-
tion affects in no way the State Constitutions.

These reports were filed by consent of the as-
sembly.

Reports of Parish Preside?its

In the absence of Mrs. Sandidge, Mrs. Heard
read the report for Caddo Parish which revealed
a very active and successful year for that auxil-
iary.

Mrs. Arthur Long, President East Baton Rouge
Parish Auxiliary, read her report with emphasis

on war work and civic activities for that group.

The Iberville Parish report was given by Mrs.
R. J. Martinez, President, showing varied activ-
ties and reporting 14 hundred dollar War Bonds
purchased by the auxiliary.

Mrs. John Dunn gave an oral report of the
work done by the Orleans Parish Auxiliary up
to January 1945.

Under new business Mrs. Young read the Pres-
ident’s report of the first conference of State
Presidents, Presidents-Elect, and Chairmen of
Standing Committees of the Woman’s Auxiliary
to the American Medical Association, held in Chi-
cago, November, 1944.

This report was placed on file.

The secretary read two letters from Dr. Talbot
regarding the State Convention. He reported
that the Executive Committee had decided to have
a one day meeting of the House of Delegates on
April 13, rather than the annual four day ses-
sion of the Society. The Auxiliary was advised
to secure permission from the War Committee on
Conventions if the officers desired to have a meet-
ing at the same time as the House of Delegates.
The Secretary then read a letter from Mr. R. H.
Clare, Secretary Committee on Conventions stat-
ing that it is present policy of the Committee to
deny application form.

Mrs. Hebert moved that we make tentative
plans for a one day convention at the same time
as the meeting of the House of Delegates. Mrs.
Long seconded the motion. It passed unani-
mously.

It was the pleasure of the Board not to submit
an application to the War Committee on Conven-
tions as in all probability the attendance will
not exceed fifty persons.

As there was no further business, Mrs. Stone
moved, Mrs. Long seconded, that the meeting
stand adjourned.

After the meeting the members were guests at
a delightful luncheon in the home of Mrs. Rhodes
Spedale.

Respectfully submitted,

Mrs. Frank J. Jones, Recording Secretary,

Woman’s Auxiliary to the Louisiana
State Medical Society.

0

BOOK REVIEWS

Handbook of the Mosquitoes of North America : By
Robert Matheson, Ithaca, N. Y., Comstock Pub-
lishing Co., Inc., 1944. Pp viii, 314, illus. Price,
$4.00.

The present war has brought to the fore the im-
portance of malaria and other arthropod-borne
diseases as military and homefront hazards. As
a result there are probably more individuals di-
rectly concerned with the control of mosquitoes in

this country and the world over than at any other
time in history. It is particularly fortunate, there-
fore, that Doctor Matheson, Professor of Entomol-
ogy at Cornell University, has produced a new,
revised and enlarged edition of his authoritative
“Handbook of the Mosquitoes of North America”
which, since its original appearance in 1929, has
been a valued guide to students of this branch of
entomology. While the literature on North Amer-

478

Book Reviews

ican mosquitoes is formidable in bulk and rich in
detail, monographic works of continental scope
have been few and long outstripped by rapid ad-
vances in knowledge. Here, in this slim volume
of 314 pages, is condensed the fruits of many years
of patient labor, in the form of a convenient hand-
book that is essential equipment for mosquito-
workers in the United States and Canada. It
makes readily available the essence of our pres-
ent knowledge of the taxonomy and biology of
North American mosquitoes, much of which could
otherwise be found, if at all, only in many separate
publications and in older lengthy and cumbersome
treatises now difficult to obtain.

The book is divided into two sections. Part I
(86 pages) is a general survey of the structure
and biology of mosquitoes, their relation to human
welfare, their control, and methods of collecting
and studying them — subjects of interest not only
to the entomologist, but to epidemiologists, health
officers, physicians, and laymen, who will find
here a clear and readable source of information.
Part II (172 pages) is a systematic account of
the North American species of mosquitoes — pri-
marily of interest to the entomologist as a working
tool.

The first part includes a detailed account of the
morphology of the adult and larval stages which
is fundamental to practical work of identification.
The life cycle, breeding, feeding and overwintering
habits, knowledge of which is essential to prac-
tical control work, are briefly reviewed. The role
of mosquitoes in the transmission of human ma-
laria, yellow fever, dengue, filariasis, and virus
encephalitides is concisely treated, with the malaria
parasite cycle described and illustrated. The fun-
damental principles of control are outlined and the
various types of control methods considered. Direc-
tions for collecting and preserving mosquitoes for
study conclude this section of the book, which con-
tains 41 good drawings and photographs to illus-
trate the textual material.

The second part, more technical in nature, pro-
vides means to identify systematically the larvae
and adults of North American mosquitoes by ap-
propriate keys to subgroups and species, and de-
scribes their group and specific characteristics.
Descriptions of 133 species are given, distributed
among 15 genera. Nearly half of these are species
of Aedes which include some of our worst day-
biting pests of marshes and woods, occurring in
untold numbers in the Arctic and along our coasts.
Aedes aegypti transmits yellow fever and dengue,
and A. cantator is an important vector of eastern
encephalomyelitis. The genus Culex, with 19 spe-
cies, includes the common night-biting “house mos-
quitoes,” which can transmit filariasis, and C.
tarsalis which has been found infected with the
viruses of St. Louis encephalitis and western equine
encephalomyelitis. Thirteen species of malaria
mosquitoes, Anopheles, are recognized in North

America, A. quadrimaculatus and A. freebomi be-
ing the most important vectors because of abun-
dance and feeding habits. While anophelines may
be distinguished from culicines by easily detected
characters, specific identification of mosquitoes re-
quires the study of minute details of structure,
color pattern, and (in larvae) of hair arrange-
ment. Such necessarily detailed descriptions are
given, with notes on the known distribution, breed-
ing, and feeding habits of each species. Illustra-
tions are provided in 33 plates of excellent photo-
graphs of typical breeding places and beautifully
executed drawings of larvae and male genitalia.
The latter afford the best characteristics for spe-
cific identification.

This edition includes over 200 classified biblio-
graphic references as a guide to the literature on
mosquitoes of America and other regions. It is
interesting to note that about forty more species
have been recognized in North America in the
fifteen years since the first edition appeared, re-
flecting our increased knowledge of this important
group of insects. (In 1901 L. 0. Howard included
only 25 species in the first general work on U. S.
mosquitoes ! )

The necessarily brief treatment of mosquito-
borne diseases and control measures includes only
passing mention of the newer developments in these
fields, but due note is made of the advent of
aerosols, synthetic repellents, and DDT. These
promising methods of attacking mosquitoes have
been largely the result of intensive war research
and already bid fair to rank in importance with
sulfonamides and penicillin as weapons against
disease.

The book is printed on good quality paper in a
neat and attractivce format, with good typography
designed for ease of reading and reference, and
with an adequate index.

While much of this volume is technical and spe-
cialized and will be used mainly by entomologists,
everyone interested in the part mosquitoes play
in public health and welfare will profit by reading
the more general chapters. The book is a mine of
useful and authoritative information. At this time
it is more than ever evident that the practical as-
pects of mosquito-knowledge are literally a matter
of life and death. Broadly conceived and sound
academic studies such as this are fundamental to
practical progress and provide part of the essen-
tial power in the complex machinery of combatting
some of the more material ills that beset man.

Albert Miller, Ph.D.

PUBLICATIONS RECEIVED

Charles C. Thomas, Springfield, Illinois: Neuro-
Ophthalmology, by Donald J. Lyle, B. S., M. D.,
F. A. C. S.

New Orleans Medical

and

Surgical Journal

Vol. 97

MAY, 1945

No. 11

THE HEALTH DEPARTMENT OF THE
FUTURE*

A DISCUSSION OF SOME PROBLEMS

J. C. GEIGER, M. D.

San Francisco, Calif.

The historical epoch in preventive medi-
cine, so ably begun by a chemist, the revered
Louis Pasteur, was given great impetus by
Robert Koch, a bacteriologist. Bacteriology
has, in turn, revolutionized our isolation and
quarantine procedures. Theobald Smith
focused attention on the importance of
transmission of disease by insects. Biggs
modernized public health practice in these
United States.

It was not many years ago that the con-
scientious health officer first offered to
quarantine the cases of communicable dis-
eases that busy practitioners happened to
report. When the quarantine terminated —
the time being usually set by convenience or
by social standing — the premises were dili-
gently fumigated. But quarantine and ter-
minal fumigation are both relatively unim-
portant features today in the control of the
common communicable diseases.

The appalling conditions of housing, haz-
ards and fatigue under which the laborers
of America lived and worked, the often con-
taminated water supply and improper sew-
age disposal, the consumption of unpasteur-
ized milk from untested herds, the accepted
presence of insect breeding areas and the
high maternal and infant mortality rate
were considered, but not too much done
about it in many communities. The attack

*Graduation address delivered at Tulane Uni-
versity Medical School, October 14, 1944.

on the diseases of the heart, cancer, tuber-
culosis, the venereal disease group, and
more recently rheumatic fever, requires
continuous and intelligent leadership. For
instance, in statistical and epidemiologic
studies of rheumatic heart disease in chil-
dren, there appears to be marked geo-
graphic difference in the incidence of the
disease. From the available information,
no definite conclusions can be drawn as to
the disease being an infectious process
though the streptococcal group is generally
associated with the laboratory findings, or
secondary to the poverty triad of insuffi-
cient and incpmplete diets, poor housing and
overcrowding. Perhaps all of these are con-
cerned in some manner.

The magnitude of the rheumatic heart as
a disease problem is recognized by health
officials. The statistical estimates of the
death rate in the group from five to 24
years is an indication of the amount of
rheumatic heart disease. Sanatorium care
for rheumatic heart disease is the most log-
ical means of checking the severity of the
infection and possible recurrence. It is also
believed worth while to try the effect of
change from cold, damp regions to warmer
ones.

Specific home care for those discharged
from sanatoriums is likewise deserving of
special consideration. It is hoped that the
medical and lay populations will come to
recognize that sanatorium care is as im-
portant for rheumatic heart disease as it is
for active tuberculosis.

DISEASE TRANSMISSION

An entirely new conception of public
health arose when healthy carriers were
recognized to exist, and when mild, atypical

480

Geiger — Health Department of the Future

or missed cases could and did account for
the spread of disease. It is now axiomatic
that, if communicable diseases are to be
controlled, we must investigate and deter-
mine their source and learn how they are
disseminated. In many common infectious
diseases we must deal primarily with per-
sons, not things.

There are fanciful routes of infection
suggested in some diseases, and some gen-
uine modes of transmission, in a few dis-
eases, do stretch the plausibilities. We must
provisionally accept all possibilities, but
never exclude the usual routes. These are,
for all practical purposes, contact, milk, wa-
ter, air, insects and animal reservoirs. Un-
der animal reservoirs, it may be of interest
to call attention to the disease undulant
fever due to Brucella - abortus. The most
important consideration in this type of un-
dulant fever is prophylaxis. Pasteuriza-
tion of milk is the only logical present
method and communities are extraordi-
narily reluctant to adopt this measure. It is
not appreciated that a brucella infection,
which has a remarkable tendency to a sub-
clinical or latent course, will biologically ex-
press itself as a chronic disease with cycles
of inactivity interspersed by relapses of
varying degrees of intensity and frequency.
Little is known concerning the persistence
of viable brucella organisms in the infected
human being. Every symptom in a person
with a positive brucella skin test or an ag-
glutination reaction is attributed to some
peculiar characteristic of the brucella or-
ganisms. No answer has been given to the
pertinent question: Why are women par-
ticularly prone to present a clinical picture
of so-called “chronic brucellosis”? More-
over, the constitutional factors responsible
for the protean manifestations have never
been considered in an analysis of brucello-
sis. It would indeed be worth the effort.
One can agree that isolation of the causative
organism is the best proof of an existing
infection, but not of existence of disease.
These differences are still overlooked. It
should be further emphasized that no diag-
nosis should be based on one single series

of laboratory tests. Repeated examinations
are essential.

The control of any disease depends, first,
upon an early and accurate diagnosis;
second, the ascertaining of the source, ve-
hicle, or avenue of infection; and third, the
prompt blocking of these. It depends also
on public confidence in the health officer,
for sometimes he must take extraordinary
steps. There is no need, ordinarily, to pre-
vent contact of persons ; but drinking water
and milk should be carefully analyzed before
their use is permitted.

One of the difficulties now becomes mani-
fest. Much laboratory work is inconclu-
sive; specimens examined today and found
acceptable may tomorrow be unsatisfac-
tory. To make milk and water safe for
human consumption means an untold num-
ber of inspections and ceaseless vigilance.
It is possible to discover an infecting or-
ganism in the water and milk, but seldom
indeed is it discovered or even attempted.
Quite often, milk handlers and others are
subjected to examinations of all types, par-
ticularly of specimens of the urine, the
feces, and from the throat; the value of the
examinations is problematical depending on
the skill of the laboratory technician and
the promptness of the investigation. Their
formidable costs to the taxpayer outweigh
the results.

Two of the modern weapons of public
health work are bacteriology and epidemi-
ology. Many of our older health officials
regard them as synonymous. But lemology,
or lemography, meaning the sum of human
knowledge as to pestilence, was long known
before bacteriology came into existence.
The term “epidemiology” is more frequently
used today. Epidemiology is a science with
ramifications, including occurrences, inci-
dence, distribution, infectivity, virulence or
the causative microbe or viric factor, and
seasonal or calendar periodicity, both pres-
ent and past. Necessarily, the epidemiolo-
gist must have a broad training in bacteri-
ology, immunology, pathology, medical zool-
ogy and . parasitology, statistics, public

Geiger — Health Department of the Future

481

health administration, and sanitary engi-
neering.

PUBLIC HEALTH BACTERIOLOGY

Bacteriology and its allies (serology, im-
munology, mycology, parasitology, and vi-
rology), cease to become separate entities
and merge under the larger field-medicine.

It would be easy to indulge in histrionics
to which the laboratory is so well adapted
and which have so often been used. The
creed of medicine has no place for histri-
onics and fantasy. We could presume, with
pure speculation, that there must be a prize
greater than the sulfa drugs and penicillin,
just around the corner. There have been
discoveries; there will be more. There are
three general ways in which the relation-
ship between physicians and the public
health laboratories of tomorrow will be
strengthened.

First, from these laboratories will come
information which will give us a stronger
hold on our knowledge of the etiology of in-
fections. The background for much of our
knowledge of diagnosis, treatment, and
epidemiology hinges on an understanding
of the etiology. This will help in many dis-
eases, the etiology of which is not known
or not understood. Differential diagno-
sis is increasingly difficult and dependent
upon the laboratory. We are encouraged
by glimpses of possible order to come in the
confusing groups of diseases caused by
viruses, rickettsiae, and yeasts and molds.
In the practice of a physician and in the
epidemiologic control of infection, knowl-
edge of the etiology has been a significant
key in development. We may lose our grip
on bacteriologic technicalities but we cannot
afford to lose it on etiology and on diag-
nosis.

Second, we are sure to have significant
technical improvements in the laboratories.
We are likely to overlook the influence of
these technical improvements on medical
practice and public health. For example,
there are thousands of culture media, and
the adding of one or two more seems incon-
sequential. Wilson and Blair devised a me-
dium which permits typhoid bacilli to grow

as black colonies while almost everything
else is inhibited. Leifson devised a desoxy-
cholate medium and the Difco Laboratories
prepared a Salmonella-Shigella medium
known as SS medium. While these develop-
ments occurred some dozens , of other cul-
ture media were added to the thousands that
exist, yet the addition of these three has im-
proved the quality of laboratory work in
connection with enteric infection so much
that epidemiologic data are changing.

The third of these general shifts is a
change in attitude. The increasing com-
plexity of our existence is forcing speciali-
zation, whether or not we approve. The day
has gone when the physician was also an
expert technician. He must turn over the
burden of technical knowledge of the labora-
tory to the technicians and end the pretense
of expert knowledge. He will have all that
he can manage to learn how to secure speci-
mens, when to get them, what to do with
them, and how to interpret the reports sent
to him from the laboratory. He will do well
to give to the laboratory the information
that it needs to examine specimens intelli-
gently. He must learn to accept the deci-
sions of the laboratory predicated upon its
knowledge of the technic with which it
deals.

The relationships between the physician,
the epidemiologist, and the laboratory will
improve with better coordination of effort.
It takes the physician as long to handle
specimens and reports from a poor labora-
tory as from a good one ; it takes the labora-
tory as long to handle a useless specimen
as a legitimate one. This wasteful gap
needs reduction. We need to guard against
the satisfaction that comes from taking a
specimen, when that specimen is meaning-
less.

Conversely, the relation of caries-resist-
ant or caries-free persons to the consump-
tion of soluble fluoride salt in domestic wa-
ter supplies should prove a valuable source
of study.

EPIDEMIOLOGY

Epidemiology must have a starting point,
and this is usually statistical. The discern-
ing health official must have a daily,

482

Geiger — Health Department of the Future

weekly, or monthly report, or all three; he
must picture the location and number of
cases with charts, and must know the pre-
vious movements of the patients. Highly
desirable is the history of past incidence, in
terms of an average for the non-epidemic
period, the so-called “norm’' or “expect-
ancy”. Such averages, when plotted in
curves and corrected as to population esti-
mates, may give reasonable endemic or con-
stant seasonal information. With such in-
formation, and with care as to deviations
(changes in population, and so on), the
health official has a useful basis for collec-
tion purposes and for forecasting and
broadcasting.

The discovery of the microbe, or ultra-
visible viric causes of disease and its vari-
ous types ; or of the parasite without its in-
termediate host, as in amebic dysentery ; or
with such a host, as in malaria ; and the dis-
covery of the manner of spread from per-
son to person, or the role of insects and
animals have added many new features to
epidemiology. But the mode of spread of
some diseases such as acute anterior polio-
myelitis, is still obscure, or a matter of con-
jecture. Presumably, contact with the case
or with the healthy carrier or missed case
accounts for the spread of many diseases,
yet elucidation of the problem of such dis-
semination is still being sought.

One of the difficulties not yet surmounted
is the apparent power of a microbe or ultra-
visible virus to produce either serious or
mild cases, or to produce few cases at some
period or for several periods, or to cause
epidemics or interepidemics (the so-called
recurrences), or great pandemics.

It is attractive to assume, in this order of
importance, that the virus of a disease like
influenza is widely distributed, that indi-
vidual and even racial susceptibility plays
an important role, and that the virulence of
pandemic strains subsides for years or be-
comes innocuous. Microbic or viric sub-
sidence from a virulent to a non-virulent
status has been suggested as a possible ex-
planation of certain vagaries in the epidem-
iology of communicable diseases, particu-
larly epidemic cerebrospinal fever; but at

present this is not quite susceptible of
proof. For instance, the facility and fre-
quency of occurrence of influenza is very
manifest, as is its dual epidemiologic role
of pandemics and interepidemics. Possibly
exaltations in virulence do occur. Two epi-
demiologic facts stand out prominently as
to the pandemic of influenza of World War
I, type unknown, that the so-called first
wave was relatively slight and occurred in
the spring; and that the second wave, oc-
curring in the fall of the same year, was
more explosive, more dangerous, more dis-
persive, more incapacitative, and more de-
pressive of mind.

Many diseases, especially measles and
scarlet fever, seem to occur in cycles or at
periodic intervals which are assumed to be
due to an accumulation of the crop of sus-
ceptibles. The recently advocated use of
pooled plasma globulins for the prevention
of measles in the armed forces could well
be applied to the civilian population. Other
diseases appear year after year with sea-
sonal regularity. The reason for such
periodicities is not yet known.

The law of etiologic specificity, or the as-
sociation of particular diseases with speci-
fic micro-organisms has led to an expansion
both of groups of recognized diseases and
in groups of acknowledged causative agents.
In the field of viruses expansion has been
spectacular. More and more it becomes
necessary to weave together the field of
micro-organisms parasitic to man and ani-
mals in such a manner as to cover the en-
tire field from a protein substance or
“germ” which is non-living in the ordinary
sense to the viruses, rickettsiae, bacteria
and fungi and to the spirochetes, protozoan
and metazoan parasites. This concept of
specificity leads to study of the manner in
which the human race and the animal king-
dom have become subject to so wide a va-
riety of illnesses caused by micro-organisms
biologically so diverse.

To regard cancer as an epidemiologic
problem may seem to be rather far-fetched,
but the progress in treatment of cancer by
newer methods of radiation brings to the
forefront the advocacy and establishing by

Geiger — Health Deyartment of the Future

483

departments of health of preventive
clinics, where precancerous conditions may
be detected; and likewise cancer in a cur-
able stage. There is no doubt that the ma-
jor reason for needless suffering and death
from cancer is delay in treatment due
mainly to fear and ignorance on the part of
the patient.

There is no doubt that continued research
in epidemiology, especially experimental,
is needed in order to understand factors as
yet unexplainable. In any event, the use of
preventive measures against diphtheria and
tetanus with toxoid, and against typhoid
fever, yellow fever, cholera and smallpox
by vaccination, has had a remarkable dffect
upon the reduction of these diseases. Pre-
ventive medicine and sanitation have not
eliminated disease, but they have held pesti-
lence in check. Because of the rapidity of
travel today, especially by air, with its as-
sociated possibilities in the spread of dis-
eases, epidemiology must more than ever
take its place as a protective science.

The impact of war on public health prac-
tice of health departments has focused in-
creased attention on diseases such as ma-
laria, on bubonic plague, on housing, on
tuberculosis, on venereal diseases, on men-
tal hygiene, on the problem of nutrition,
and on the inter-related preventive, medical
and hospital care of those ill in a commun-
ity. These are briefly discussed.

Malaria has always ranked high in the
list of pestilences that are a blight to health,
efficiency and morale. This disease may in
a short period of years injure, and even
wreck, a civilization fostered for years.
Particularly does malaria affect the effi-
ciency of labor, and the cost of this disease
to industry, when prevalent, must be enor-
mous. The pernicious “contract” work in-
cidental to tropical areas is a result of in-
dustry protecting itself against the loss of
time and money, despite the admitted fact
that the tolerance for malaria in native
populations may be considerable. For in-
stance, the average parasitic rate in blood
film surveys on Workers on banana planta-
tions may be as great as 25 to 30 per cent.

The importance heretofore attached to en-
larged spleen index rates in adults in the
tropics and the Orient has been markedly
discounted by many workers. If control of
the breeding areas of the Anopheles mos-
quito, if of a type that is a potent vector,
can be obtained, malaria would cease to be
a disease of importance. It must be re-
called, however, that only a few Anopheles
mosquitoes, after emerging from the larval
state, will play an important role. This role
too is quite often dependent on the people,
their environment and the clinical recogni-
tion of the disease with its proper treat-
ment. This brings to the forefront the dis-
tinguishing of a new infection from ordi-
nary relapses. This is generally a doubt-
ful possibility except in infants. It is this
point that makes the returning soldier and
sailor from known infected regions of such
importance to the health official of areas
proved to have Anopheles breeding that are
potent vectors.

It is an epidemiologic fact that many per-
sons, previously exposed, carry the para-
sites for years. The elimination of relapses
or the destruction of the parasites in the
blood by chemo-therapeutic methods are
still difficult problems. So long as mili-
tary personnel will be returned uncured, or
in a resting or subclinical stage, or when
true relapses occur especially in treated per-
sons, or be negative clinically, but micro-
scopically proved positive parasitic carrier
state exists, there must be adopted mosquito
control measures in many communities in
this country. These generally consist of
drainage of unnecessary water storage ; the
treatment of all permanent watei; courses
with oil, paris green dust mixtures, or the
new insecticide, DDT, called dichlor-diph-
enyl-trichloroethane, and the use of top-
feeding fish ; the destruction of mosquitoes
in human habitations and prevention of ac-
cess to humans by proper screening; the
elimination of migration of mosquitoes by
various types of transportation ; the propor-
tional degree to which the different species
of Anopheles are in nature vectors of ma-
laria, and finally blood indices of population

484

Geiger — Health Department of the Future

groups and their subsequent treatment of
those persons found infected.

Let no health official forget that finan-
cial and offical cooperation is necessary for
control and that there is yet much to be
learned to assure eradication of malaria.
Moreover, malaria control will continue to
play a major role in the war efforts of this
and other nations.

Besides affecting malaria, climatic con-
ditions seem to affect other diseases and
their virulence. For instance, African
sleeping sickness is apparently limited to
certain regions suitable to the tsetse fly.
Bubonic plague depends not only upon the
flea of the infected rat or other rodent, but
also quite definitely upon humidity.

PLAGUE

Plague erupted as a pandemic at the be-
ginning of this century, and its previous his-
tory, and course during the past forty years
suggest an analogy of a subterranean fire
with periodic eruptions. From 1900 to
1910 outbreaks of varying intensity oc-
curred in many parts of the world, and in-
cluded California. Then came the explo-
sion in Manchuria with 60,000 cases and
deaths of pneumonic plague during 1910
and 1911. This was followed by a relative
quiescence to recur in another devastating
flare of 10,000 pneumonic cases in the same
areas in Manchuria during 1920 and
1921. During these first twenty years
of the century, both ports and coun-
tryside of the United States were invaded
and the disease well established among ro-
dents, apparently of all varieties. People of
New Orleans were infected (1913-1914).
Two sharp explosions of pneumonic plague
occurred in California (1919, 1924, and
1925) among small numbers of peoples; and
throughout this period similar or compar-
able manifestations of continuous activity
of the infection were evident in Asia, Africa
and South America.

The past twenty years have not been
characterized by spectacular outbreaks in
the United States. The appearance, how-
ever, of spasmodic cases from year to year
and the detection of many epizootics among
rats and field rodents in the western states

afford a warning of the persistently glow-
ing embers.

Today the world is disorganized and even
though reports are limited or fragmentary,
its frequent occurrence in man has been an-
nounced during the past several months in
Egypt, Morocco, Dakar and other countries
of Africa ; in the Azores ; in Bolivia, Peru
and Ecuador; in India and Indo China; and
close to our western shores in Hawaii. Cur-
rent investigations among field rodents of
western United States reveal the fact that
it is smoldering among approximately
twenty-five species of these animals includ-
ing ground squirrels, prairie dogs, wood and
field rats, and field mice in locations scat-
tered throughout forty per cent of our con-
tinental territory and extending into the
western borders of the plains states. Kin-
dred species of these rodents are distributed
through ranges which reach into the gulf
states and well north into the mid-Atlantic
group. The studies available do not permit
of conclusions relative to the virulence and
course of plague. It seems probable that
rats are no less prevalent in the towns and
cities than they were in past years, but
salvage drives have definitely activated
harborages. Large populations, however,
of these potential plague carriers remain,
and their presence is regarded by many
people with the same complacency exhibit-
ed towards the family cat. Will the intro-
duction of foreign strains of plague into
the rodent population result in explosive
eruptions of the disease? No man can tell.
It is not the belief of those who are familiar
with the conditions under which plague
has developed its great devastations that
our country is threatened with such. The
stage, however, is set for the introduction
or reintroduction of this disease into our
densely populated areas and cities of the
eastern half of the country, and for its pos-
sible extension into our own middle west.

What is to be the defense against this
threat? There is no specific proved remedy
for plague in the individual. The mortality
varies from 15 to 50 per cent among cases
which are classified as bubonic, the rate
rises from 70 to 80 among those regarded as

Geiger — Health Department of the Future

485

septicemic, and almost all primary pneu-
monic cases are fatal. Reports indicate that
some of the newer sulfonamide drug pre-
parations may be of therapeutic value in
bubonic cases, but little promise has been
offered yet in the septicemic and pneumonic
cases.

The control and eradication of bubonic
plague from the afflicted community re-
solves itself into the control and destruction
of the rodent carriers and their accompany-
ing insects. This procedure has been and
may again be most costly to the community.
The control of extension of a pneumonic out-
break is that of a most rigid and complete
segregation of the patient by trained at-
tendants under strict technical isolation dis-
cipline. Previous to 1925, as is often the
occurrence in these United States, the pres-
ence of plague in a community was an-
nounced by the occurrence of a human death
from the disease, and the work of preven-
tion began. The practice in some cities of
consistently collecting and examining ro-
dents and their insects has forewarned au-
thorities of the presence of the infection,
and an indication for its elimination.

The remedy is prevention and not too
little of it or too late. This necessitates the
establishment of an adequately organized
and sustained program of examination and
control of the rat population and their in-
sects in a community. The institution of
these measures in some localities may be re-
garded as urgent.

HOUSING

Environment plays a most important role.
Natural resistance to disease must assert it-
self in many ways, and this may partly de-
pend upon dietary factors, partly upon rest.
Fatigue is considered a marked contributor
to tuberculosis and cholera. Overcrowding,
because of improper housing conditions,
undoubtedly plays its part in the spread of
respiratory and other infections and epi-
demic cerebrospinal fever.

For many years somei departments of
public health have condemned dwellings as
unfit for human habitation, and places of
business as insanitary and rodent-infested.
In a sense, then, the efforts applied by de-

partments of public health to the problems
of housing and health have been negative
and destructive. If a health department de-
cides in its wisdom to destroy tenements
that are unfit for human dwellings, then it
is equally logical to demand decent dwell-
ings for replacement. To the average health
officers of American cities the problem
quite often presents difficulties; and it is
no novelty that some of these difficulties
may result in political backfires.

Many of these dwellings are the forgotten
houses, derelicts from the past, forsaken by
their owners and left as decaying, rundown
structures, where people of low incomes
must live. They are the first cousins to the
slum tenements; blights on the city — so-
cially, economically, and from the stand-
point of public health.

America has always had a consciousness
toward slums, and there is seen today a
dawning perception of our inherent right
to decent conditions of living. Bad hous-
ing conditions must have cost this nation
so much that posterity cannot begin to
liquidate the debt.

The forgotten house, with its insanitary
toilets, and sometimes its overflowing cess-
pools, its overcrowding, the lack of light
and air, the coldness and the dampness, the
lack of screening against mosquitoes and
flies, and the fire and accident hazards, all
lead to a higher mortality. Housing and
health must receive increased thought and
attention, particularly in cities, and some
coherent plan should be adopted by the Fed- •
eral government.

It is a well established fact that the qual-
ity of our housing has a direct relationship
to the quality of our health and our morale.
The statistics growing out of literally hun-
dreds of surveys conducted over the past
ten years indicate it is not just accident or
coincidence that the large percentage of
our disease, crime, and high governmental
costs are concentrated in our slum and
blighted areas. It has been said that one-
third of the nation is ill-housed. I have
no reason to quarrel with this generaliza-
tion. I do know, however, that that part of

486

Geiger — Health Department of the Future

the nation known as the deep South is one-
half ill housed.

This is the debit side of the ledger. Now
let us look at the credit side. Beginning
January 1, 1938, this nation started out on
a program to end the slum, and all the evils
attendant upon it. It was a modest begin-
ning, and the funds made available repre-
sented an infinitesimal portion of the prob-
lem. However, between that time and
Pearl Harbor, when all our housing re-
sources were dedicated to the war effort,
the South had built thirty-five per cent of
all the houses constructed under this pro-
gram, although it represented only about
twenty-four per cent of the population of
the country. In other words, when many
other sections of the country were refusing
to recognize the facts, and were fighting
the efforts to clear slums and provide de-
cent housing for the slum dwellers, the
South was recognizing the facts, and cour-
ageously taking steps to meet them.

TUBERCULOSIS

Perhaps never before have we as a people
been confronted with public health prob-
lems of such magnitude as face us today.
Our efforts at solution may influence the
destiny of this and other nations beyond
the count of time.

In no single endeavor do we have such
a clearly written script before us as in the
direction of health measures for the con-
trol of tuberculosis. Today we are pos-
sessed of knowledge which if put into exe-
cution would remove from our midst many
diseases and areas of potential danger.

One of our most insidious diseases is tu-
berculosis and to many this disease is con-
sidered the number one postwar disease.
In spite of the effort of years, thousands
of people in these United States die yearly
of this disease. In the main, it takes its
heaviest toll from those in the most pro-
ductive years of life, namely the early adult
years. The economic loss is enormous. Yet
the principles of control and prevention are
well known to health authorities. Tuber-
culosis is a communicable disease. It is not
inherited, but is spoken of as a family dis-
ease because of the plentiful opportunities

for contact within dwellings, especially
where there is lack of education concerning
the danger and much overcrowding in sub-
standard homes in war industrial areas.

Tuberculosis is always present in any
community. Transmission never arises de
novo, but one case always comes from an-
other. It is because of the slowness of its
development that much of the drama is
lost. If the immediate contact was followed
by the immediate development of symp-
toms, respect for its communicability would
be increased. In other words, the unexam-
ined and sick nurse maid who cares for the
baby may so infect that child that a break
in health may not come for years. The ini-
tial contact then has long been forgotten,
or perhaps never known.

The tubercle bacillus knows no economic,
racial or caste boundaries. It is true that
the poorest people in a community are the
ones who suffer most. No individual, how-
ever, is safe if a laundress, cook or house-
maid employed in that community is scat-
tering tubercle bacilli in family or other
groups.

The methods of control are in our hands.
On paper it is an essentially simple pro-
cedure to find the clinically active cases,
isolate and treat, not restoring them to
community life until they have been ren-
dered bacteria free and never discontinuing
supervision of the individual or the family
group because of the danger of reactiva-
tion.

What are these methods? In the hands
of authorized experts the entire community
should be investigated. This may and has
been done by mass x-rays. Particularly
should members of labor unions be given
the opportunity to know about the state of
their chest health. Especially should those
members of the community who apply for
relief be x-rayed. This chronic disease is
frequently the cause of inability to hold a
job.

For the child, a simple skin test, the
tuberculin test, given at regular intervals
throughout the childhood years will give
definite information as to whether or not
the child has taken the organisms into his

Geiger — Health Department of the Future

487

body. Because a child’s contacts are neces-
sarily few, the infecting person usually can
be found without much difficulty when the
test first becomes positive.

The negro of the southern states is one
of the South’s assets as a worker and citi-
zen. Poor living conditions, however, have
much to do with facilitating the spread of
tuberculosis. With the negro it is as with
other primitive races, they have not had
the partial immunization received through
generations of contact with the disease.
Coupled with the degree of susceptibility
is the lack of education as to prevention,
substandard housing, and insufficient clinic
and hospital facilities. In conserving negro
health, the South will preserve its economy
and the happiness and well being of some
of its most useful citizens. It is gratifying
to many thoughtful health officers of south-
ern birth to see activity against preventable
diseases in the negro race. Unfortunately,
quibbling over the academic question of
whether the negro has some racial tend-
ency producing high mortality seems the
rule. Tuberculosis is taking more than fair
toll of this group. In 1942, the negro
mortality rate was 117.4 per 100,000 while
the white rate was 34.9. Improvement of
living conditions and reduction of mortal-
ity from tuberculosis in the negro race
should be realized by health departments.

An understanding of the magnitude of
the general problem, better law making,
and money made available through taxation
are the elementary needs. An open case
of tuberculosis in Texas who refuses hos-
pitalization should not be allowed to come
to Louisiana and continue infecting the
community. This type of migration, es-
pecially in this industrial war era, has
proved costly to communities. Likewise,
the recalcitrant case should be put under
control. The active cases can be found.
With miniature films, thousands of x-rays
can be taken daily. The x-ray film of
every patient, whether physician’s office,
call or hospital, has been advocated. After
the cases have been found the next step is
isolation until' they may safely return to
community life, or permanent custodial

care if they are found to be too advanced
for recovery. The cost of such a program
is only a fraction of what is now paid out
in the care of the tuberculous. The earlier
the case is found the less it costs the com-
munity in money and in mortality. In Cali-
fornia we estimate that an early case costs
on an average of $2,500, while an advanced
case costs $5,000, just twice as much. One-
third of the cases reported die in the year
they are diagnosed.

With the war approaching its close we
begin a new era in government in which
as never before our country must assume
leadership. Statistics of the spread of dis-
ease in the war-torn and occupied countries
have not been available but already the
news is broadcast that one person in every
200 in Italy has tuberculosis. When the
plight of countries such as Poland, Greece,
the Low Countries of Europe are consid-
ered it is realized that this disease will have
assumed the proportions of a world-wide
epidemic in which mass slaughter from
disease will continue for generations unless
known methods of control are applied early
and amply supported by governments.

NUTRITION

With the possible exception of pellagra,
clear cut clinically defined disease entities
of dietary origin have not played a large
part in mortality and morbidity statistics,
so in the past the attention of public health
officials and physicians interested in pre-
ventive medicine has not been focused on
the role of nutrition in the public health
program. It is now recognized, however,
by many physicians, dentists, dietitians,
nutritionists and nurses and others inter-
ested in the public welfare that malnutri-
tion and borderline diseases are not un-
common in the low income groups and also
among persons with sufficient incomes but
with faulty food habits. Malnutrition has
been spoken of as “the great disease of the
American school child.” Perhaps the work-
ing war mother has caused trouble here-
tofore not considered in the war effort of
women.

That malnutrition in this and other coun-
tries is now recognized as a major health

488

Geiger — Health Department of the Future

problem, not only in children but also in
adults, is emphasized by Sebrell. He states:
“The prevention of malnutrition and the
deficiency diseases is probably the greatest
and most complex problem in public health
that this country has ever had. The exact
extent of physical disability, economic loss
and disease directly or indirectly related to
nutrition is unknown, and yet there is every
indication that malnutrition is very wide-
spread. Some physicians who do not see
many cases of advanced deficiency disease
feel that the importance of nutrition is be-
ing overemphasized. In every clinic in
which close observations are made and the
more refined methods of diagnosis are
used, many unsuspected cases of malnutri-
tion are recognized, and every study reveals
the importance of mild degrees of defi-
ciency in producing symptoms, the cause
of which were hitherto unrecognized. Fur-
thermore, it is significant that almost all
practicing physicians are prescribing vita-
min preparations for more and more of
their patients.” The recent current com-
ment in the Journal of the American Med-
ical Association that the citizens of this
country spent 179 million dollars in 1943
for vitamins is illuminating indeed.

In terms of dietary adequacy, it is doubt-
ful that the world has never had enough
to eat. So-called over-production and ap-
parent surpluses have in reality been fail-
ures to secure adequate distribution. Cer-
tainly the greater part of our population
underwent food rationing with success even
if it did bring alterations in food habits.
That part of our population who will either
not cooperate or who are unable to under-
stand the fundamentals of nutrition are
most likely to suffer, and with them the
community and there on to their children.
Food rationing in America began with
many doubts but it appears to have been
successful.

The influence of diet on physical and
mental fitness is being evaluated today
more than ever before. Diets may be quan-
titatively adequate but may have qualita-
tive deficiencies. The method of prepara-
tion is important in determining the loss,

if any, of possible nutritive value. Every
effort should be made to provide nursing
mothers and children with milk, vegetables
and fruit in sufficient quantities. Vitamin
fortification of foods often complicates the
problem. Practical demonstrations to
housewives and school children by trained
nutritionists should be the rule rather than
the exception. Nutritional hygiene is a new
and complex subject.

VENEREAL DISEASE

Venereal disease control in wartime has
the advantage of a free flow of funds. The
Congress of the United States during the
past three years has appropriated $12,500,-
000 towards venereal disease control, of
which $10,276,200 are actually distributed
to state and local health departments. The
48 states and their local health departments
in 1944 appropriated $4,666,700 — from
state and local funds toward venereal dis-
ease control, thus making a grand total for
this fiscal year of $14,942,900 spent on
venereal disease control. An alarming sit-
uation in this financial record, however, is
shown by the fact that only 31 per cent
of the total venereal disease control expen-
diture is appropriated by state and local
health departments.

Prostitution is, perhaps, the main single
factor in the dissemination of venereal dis-
eases. In spite of all our efforts to contrpl
venereal diseases there is now occurring an
increase in the prevalence of gonorrhea and
syphilis in the civilian population of the
United States. The amount of venereal
disease is drastically lower than would have
been experienced had prostitution not been
adequately and actively repressed during
the wartime period. The action taken in
the repression of prostitution has been con-
sidered by many as a patriotic wartime
duty to protect the armed forces and war
workers without full public understanding
of the importance of such a procedure to
the local community health and welfare.

All cases of venereal disease in the armed
forces have been carefully questioned by
medical officers or their representatives,
and the information regarding the civilian
sources and contacts has been promptly

Geiger — Health Department of the Future

489

reported by the military to local civilian
health departments. This program has re-
sulted in the finding of a large number of
civilians infected with venereal disease.
The epidemiologic program has been suc-
cessful and has contributed markedly to the
reduction in the potential incidence of the
diseases that would have been reached, had
it not been for this epidemiologic service.

In addition to this, the United States
Public Health Service, usually through
' state health departments, has, with the as-
sistance of Lanham Act funds, provided
so-called rapid treatment centers for cer-
tain women found to be infected with ven-
ereal diseases. The treatment of these wo-
men at these centers has been expedited
and they have been generally returned to
the community in a non-infectious state.

Much effort has been made in the last
five years to shorten the treatment period
of syphilis and gonorrhea. These attempts
have resulted in the one-day treatment, the
five-day treatment, the eight-day treat-
ment, the ten-week treatment for syphilis,
and the one-day and five-day treatments
for gonorrhea. Unfortunately, the major-
ity of these accelerated treatment plans
have proved ineffective generally. As a
result of these accelerated treatments, how-
ever, we have made definite progress in thel
treatment of venereal diseases. It is nowij
felt certain that the so-called Eagle or ten
weeks treatment for syphilis is relatively
safe therapeutically, and efficient in the
treatment of syphilis.

It is felt that the so-called rapid treat-
ment for gonorrhea with sulfa drugs is only
effective in 50 per cent of the cases treated,
and that the one-day penicillin gonorrhea
treatment is effective in 70 per cent of the
cases. Statistics are available indicating
the fallacy of accepting the asymptomatic
state of a patient with gonorrhea, who has
been under sulfonamide therapy, as suffi-
cient evidence that the patient has been .
cured. It has been demonstrated that a
third of the patients are still infectious
during this clinically asymptomatic state,
and therefore laboratory observation per-
haps for months is necessary to assure bac-

teriologically negative cultures. It is pos-
sible that a combination of arsenicals and
penicillin in the treatment of syphilis may
prove to be efficacious in the light of future
experience and may ultimately reduce the
treatment of syphilis to a matter of a few
weeks rather than one of months, and also
that a combination of the sulfonamides and
penicillin treatment in gonorrhea may re-
duce the treatment of gonorrhea to a mat-
ter of days rather than a matter of weeks.
In all these treatments, however, it is safe
to postulate that a prolonged observational
period should in the future be indicated,
as it is now, to assure the patient and the
community of his complete freedom from
the disease.

In San Francisco, a new approach has
been made from a socialistic point of view
in the prevention of prostitution in that
there has been established a psychiatric
service for special types of cases. Many
women have been found to be amenable to
psychiatric redirection, and if such a pro-
gram is continued in the postwar period,
it will undoubtedly lead to a potential re-
duction in the future recruits to the field
of prostitution. The war has led to an
intensification of the venereal disease edu-
cation program which is perhaps the most
important single factor leading to the suc-
cess of any venereal disease control pro-
gram. Sex hygiene instruction urges serv-
ice men not to expose themselves to infec-
tion, and to avail themselves of prophylaxis
if they do nevertheless expose themselves.
Experience in public health education in
general has shown the importance of con-
tinuing educational programs of this type
and repeating them at frequent intervals
in order to achieve sustained success.

With the advent of World War I, Con-
gress passed an act which established the
United States Interdepartmental Social
Hygiene Board and Division of Venereal
Diseases in the United States Public Health
Service. In addition to this they appropri-
ated funds to aid the states in establishing
adequate venereal disease control pro-
grams.

If this program had been continued, in

490

Geiger — Health Department of the Future

all certainty the incidence of venereal dis-
eases at the present time would have been
negligible in comparison to their present
incidence. With the cessation of hostilities,
however, Congress and many state govern-
ments in the interest of economy cut ap-
propriations, and cities did likewise in the
maintenance of venereal disease control
programs. With money and personnel
hopelessly curtailed, these auspicious begin-
nings became static. It required many
years of work to build up more adequate
local and state activities to interest the
local communities in supporting local ven-
ereal disease control programs. It was not
until 1937 and 1938 that sufficient public
support had been achieved to make it pos-
sible for Congress again to appropriate
venereal disease control funds on a nation-
wide basis to develop our present venereal
disease control program.

What will be the effect of the postwar
period on this appropriation? A great
wave of economy may be expected in Fed-
eral expenditures. All war emergency ex-
penditures will undoubtedly be slashed. The
postwar period will present a need for
greater financial expenditure in venereal
disease control than was presented during
the wartime period. The . experience of
World War I showed that following hostili-
ties there was a letdown in the repression
of prostitution. There was an increase in
the prevalence of syphilis and gonorrhea
occurring out of these conditions. Unsound
financial and administrative restrictions
resulted in eliminating trained personnel
and otherwise handicapped essential public
health, medical, social and educational ac-
tivities in venereal disease control.

At present there is a wide degree of regi-
mentation necessitated by the emergency.
This will, to a large degree, be limited in
the post-war period. Repression of prosti-
tution was facilitated because many women
who are professional prostitutes and who
were forced out of business were able to
secure good wages in the wide variety of
employments. Many war industrial jobs
will terminate with the cessation of hostili-
ties thus throwing many people out of

work, including former prostitutes, and
those on the verge of prostitution. No
longer finding themselves in a lucrative em-
ployment, they will be welcomed by exploit-
ers and facilitators back into the prostitu-
tion racket. It is therefore important that
the interested citizenry of the community
must do everything possible to make sure
that the public throughout the country is
convinced of the importance and necessity
of the repression of prostitution as a per-
manent policy.

The educational program which is now
being conducted so splendidly by the armed
forces must be continued when these men
are in civilian walks of life. When these
men contract venereal disease in civilian
life they will need diagnostic and treatment
service. These must be furnished in the
civilian community.

No matter how excellent diagnostic and
treatment methods may be, they do not
greatly affect the prevalence and spread of
venereal diseases unless they are generally
available to everyone, and unless they are
actively applied to the infected person.
Moreover, the widening of the application
of premarital and prenatal serologic tests
must be fostered. Much has been said as to
the high syphilis rate in Southern states
among the negroes. If the mortality rates
for syphilis in the United States for 1942
are correct, then the rate of 8.8 per 100,000
for white and 45.2 for negroes, is a defi-
nite and wide discrepancy. The serologic
rate for syphilis in negro Selective Service
Registrants was reported by the United
States Public Health Service to vary in the
various age, rural and urban groups. These
results reached the astonishing high rate
in 36-40 age group of 377.5 per 1,000 in
the urban negro and 403 in the rural ne-
gro. If syphilis is a part of the problem
of delinquency, then negro delinquency is as
much a problem to the so-called dominant
race, as it is a curse to the colored people.
Persuading infected persons to seek diag-
nosis and treatment will require much more
educational and epidemiologic service than
. is now provided by any civilian community.

Interest in age distribution of venereal

Geiger — Health Department of the Future

491

disease in San Francisco is directed to the
under 18 group. In 1942, 1.6 per cent of
the cases of syphilis were in this classifica-
tion. In 1943 the percentage had increased
to 3.1 per cent and with only nine months
of 1944 reported, the trend appears defi-
nitely upward.

The percentage of cases of gonorrhea in
the under 18 group is even higher than for
syphilis but shows the same general trend
— 6.0 per cent in 1942, 10.2 per cent in
1943, and for the nine months of 1944, 7.8
per cent. In each year, the percentage of
females under 18 is greater than for males.

The specter of juvenile delinquency to
many social workers is not pleasant to con-
template.

MENTAL HYGIENE

Another epidemiologic area of prevention
which is destined to become more and more
a public health matter is that of mental
hygiene. Mental maladjustments and mi-
nor disturbances are gradually coming to
be regarded as important health matters
rather than eccentricities or moral obliqui-
ties for which the culprit should be pun-
ished or ostracized. Educators, social work-
ers and physicians have long recognized a
considerable proportion of our population
as incapable of, rather than unwilling to
assume the minimum responsibilities that
go to make up good citizenship. Censor-
ship, neglect, and punishment have not re-
sulted in improvement of behavior, and the
victims of this method of treatment have
become increasingly unfit and unhappy.

During the recent war years, a great
amount of information has been accumulat-
ed as to the particular traits of men which
make it impossible for them to fit into the
routine of the various armed services, and
with the publication of the figures con-
cerned with the numbers which have been
rejected by draft boards, or discharged
from the services as neuropsychiatric cases,
the general public is fast coming to a reali-
zation that this is no insignificant matter
either for the armed forces or for the ci-
vilian population. The last world war pro-
duced many cases of “shell-shock” so-called,
which were popularly regarded as a special

form of war casualty. Even then, psychia-
trists recognized these war breakdowns as
cases of mental disorder, ranging from mi-
nor disabilities to actual psychoses, and
knew them to be the old familiar disturb-
ances long known in civilian practice. Fur-
ther than that, it was clearly recognized
that a large proportion of these disabilities
could have been avoided if more care had
been exercised in screening out those vul-
nerable personalities especially susceptible
to the development of mental disorders un-
der stress of any sort.

There is no little danger that this prob-
lem will be passed off as a military matter,
for which the civilian community has no
responsibility. Some psychiatrists in the
armed forces have even gone so far as to
say that discharge from the army merely
meant releasing men who would fit success-
fully into civilian life. There could be no
greater mistake. Many of those unfitted
for Army life have already failed in civil
life, and many more of the tragic failures
in civil life bear striking resemblances to
the military failures.

Experience is gradually beginning to
make clear that the treatment of adult so-
cial derelicts does not accomplish much ; but
these social derelicts are too often the heads
of large families, and health departments
the world over are well acquainted with the
conditions under which they live.

The time is not far distant when the ab-
surdity of present day health measures will
be recognized, not only by the doctors,
nurses, and social workers who are already
well aware of much of this, but by the great
bulk of human beings who cast the votes
and indirectly control the public purse
strings. Giving incompetents more money
for “busy work” does help a little but the
essential problem remains the same. It is
now common belief that children should not
be blamed, but that the parents should be
penalized. Nearly all of these problem par-
ents have themselves been problem chil-
dren. The records of our juvenile courts,
of our clinics, and of our schools show
clearly enough how self-perpetuating this
cycle is. There is a tragic irony in the

492

Geiger — Health Department of the Future

statement so often made by these parents
in defense of their children, — that Johnnie
or Mamie are just the same as their parents
were, and that they will outgrow it. All
that the children do is to grow older, have
their own children, and so keep the ball roll-
ing. If we are ever to have even a partial
solution of the present appalling situation
with regard to mental illness, preventive
work must begin in childhood and mental
disability must be regarded as a health
problem quite as important as is the control
of epidemics. The gap between a difficult
child and a neurotic or psychotic adult only
seems wide, and unquestionably much adult
mental illness will be prevented when the
difficulties of children are ironed out.

Departments of public health have pro-
ceeded on the hypothesis that a diagnosis
of feeble mindedness once made should not
necessarily mean an absolutely incurable
condition. It is fully recognized, however,
that deficiencies in brain tissue can never
produce a normal mentality. Moreover, the
cases regarded as due to inherited defects
bring up another moot question of the pre-
vention of the birth of additional children
from the original parents. And, further-
more, humanity demands that, once born,
a child so mentally handicapped must live,
and must be adequately trained or con-
trolled. To be effective, therefore, the ap-
plication of modern methods of mental
hygiene as a public health procedure must
begin early in order that a distinct menace
to society may be scientifically and humane-
ly obviated.

.MEDICAL CARE

Recent months, more than ever before,
have seen the development of concentrated
interest in and extensive discussion, espec-
ially in legislative halls, of the problem of
medical care, particularly as to govern-
mental participation in their solution.

American medicine today leads the world,
scientifically and in all its humane aspects.
Much of the discussion is built around pub-
lic health and the lack of medical care.
Public health, as such, is really not the duty
of organized medicine. It is the duty of
government, whether it be city, state or

nation. Therefore, if there has been any
neglect of public health in any locality, the
blame should be placed where it belongs —
on government.

Adequate medical care in all its ramifica-
tions (which would include clinics, dispen-
saries, hospitals, and the necessary labora-
tory tests and home visits) should be di-
vided into three groups: (1) those who
cannot pay because of a disproportion be-
tween income and their medical needs; (2)
those who should pay but find themselves
in great difficulty because of their own
budget limitations and ineptness in plan-
ning for illness; and (3) the smaller group
who can pay for anything at any time.

Experience with the first group is avail-
able in San Francisco. With the second
group, there is no doubt that medical opin-
ion has been divided, but that division is
more apparent than real. The division is
in two schools: (1) compulsory health in-
surance, which many feel very definitely
that these United States should never
adopt; (2) voluntary health insurance
which a large portion of the medical pro-
fession thinks should be the American sys-
tem, and whereby the patient may have, at
a reasonable cost, choice of hospital and
choice of physician. The dentist and the
nurse, especially in home care visits, are
seldom, if ever at all, mentioned in such
a scheme, and yet the nurse in indispen-
sable for the care of the ill, as is likewise
the dentist in a great variety of diseases.
Moreover, the seeming neglect of post-
graduate training for the physician is an
oft-repeated challenge not yet entirely an-
swered by organized medicine or the med-
ical colleges.

In San Francisco the limitations of gov-
ernment in medicine are thought consistent
and there is no medical or public health
neglect within the budget allowed. The in-
stitutions of the Department of Public
Health include the San Francisco Hospital,
the Laguna Honda Home, the Hassler
Health Home and the Emergency Hospital
and ambulance service. More closely al-
lied to the institutional section administra-
tively, but also very closely related to the

Geiger — Health Department of the Future

493

medical-dental-nursing section, are the
chest diagnostic centers, the outpatient ob-
stetrical service, the venereal disease diag-
nostic and treatment centers and the city
physicians, treating persons in their homes.

If the p^ ^ram of public health should
include hospitalization and home care of
the indigent (classified as such because of
their medical needs and limited earning
capacity) , which has not been the case here-
tofore in many localities, then again the
matter is for government through health
departments and not through organized
medicine. There still would remain the
care of the moderate income group. It is
this group that becomes the piece de re-
sistance for argumentative health insurance
advocates.

It may be of interest to note that there
has been a truly spectacular development
of non-profit health plans during the past
eleven years. Despite the development
which has taken place there are many who
believe, and many who contend, that these
plans have reached their full development
and cannot be expected to reach a large
proportion of the people. It has been pre-
dicted, however, that with the support of
the medical and allied professions, and with
the support of hospital trustees and execu-
tives, the people of this country can be
relieved of the financial burden of curative
health care within a reasonably few years
through medical plans and the companion
hospital plans.

California has the honor of being a pio-
neer in the health service plan movement.
The first free choice hospital service plan
was organized in Sacramento in 1932, and
the first state-wide medical plan was or-
ganized and incorporated under the Cali-
fornia Non-profit Corporation Law on Feb-
ruary 2, 1939. Much of the credit for the
present nation-wide development of health
plans must be given to California. The
administrative members comprise physi-
cians and laymen who are leaders in other
fields, and management is vested in a Board

of Trustees who are elected by the admin-
istrative members.

California Physicians’ Service differs
from other prepayment medical care plans
in two fundamental respects. First, the
professional membership is open to any
doctor of medicine licensed to practice his
profession in the state. He does not have
to be a member of the County or State
Medical Society. The professional member
has agreed, in writing, that all compensa-
tion for professional services that may be
rendered by him to any beneficiary mem-
ber shall be limited to the funds collected
by the California Physicians’ Service
monthly from beneficiary members. This
limitation is called the “Unit System,” and
it has the effect of limiting liability on the
part of California Physicians’ Service for
the cost of medical care to the funds col-
lected each month. In other words, Cali-
fornia Physicians’ Service cannot have a
deficit, nor can it have a surplus.

The unit system operates as follows:
Dues collected in each month from bene-
ficiary members are segregated into two
funds, an administration fund and a pro-
fessional members’ fund. The administra-
tion fund is used to defray operating costs.
At the end of each month, the professional
members’ fund for such month is distrib-
uted to those professional members who
have rendered medical or surgical services
during the month. This distribution is ac-
complished by assigning to each type of
professional service an agreed-upon unit
value. For example, an office call is one
unit, an appendectomy is fifty units. At
*the end of each month, all units of service
rendered in the month are added, and the
sum of dollars in the professional members’
fund is divided by the total number of such
units of service. The figure resulting is
the dollar value of each unit of service for
that month. The professional members’
fund is then disbursed to the professional
members on the basis of the number of
units of service rendered by each during
the month. Hence, each doctor receives a
sum equal to the number of units of service

494

Geiger — Health Department of the Future

rendered by each during the month multi-
plied by the dollars of unit value.

It was early seen that the amount of dues
paid (namely $2.50 per month — $1.70 for
medical and 80 cents for hospitalization)
for benefits that ranged from periodic
health examinations and refractions to all
types of major surgery, was going to prove
‘inadequate. California Physicians’ Service
has designed a fee schedule which repre-
sents fees that the medical profession in
California would normally charge through
channels of private practice to families
earning less than $3,000 per year. As the
full coverage program progressed, it was
unreasonable to expect the medical profes-
sion to continue indefinitely under these
conditions.

It can be safely said today that the med-
ical profession of California has actively
participated in the development of prepay-
ment medical and hospital care and has
made a sound investment in its California
Physicians’ Service, the potential of which,
both from the social and economic points
of view, represents unknown resources
which only time can reveal. The California
Physicians’ Service should receive the sup-
port of labor organizations and Federal
Housing Agencies involved in housing
workers in areas of concentration of pop-
ulation due to war industries. The bene-
ficiary members are those persons, who,
upon payment of monthly dues, are entitled
to secure when needed, medical and surgical
and related services for any professional
member. Hospitalization, drugs and appli-
ances are in some instances supplied to
beneficiary members.

Furthermore, it may be of interest to
point out that on September 30, 1938 the
Health Service System of San Francisco
was adopted by the Board of Supervisors
for city employees of the City and County
of San Francisco. The initial charges per
month for employed members averaged
$2.50 and for minor dependents $1.50.
However, as the system progressed, it was
necessary to adjust the fees and at the
present time the charges for employed
members are $2.80 a month and for minor

dependents $1.80. Adjustments have been
made in the charges of retired members
and dependents over the age of 62. There
are approximately 15,000 members in the
Health Service System at the present time.

This system is also operated on a unit
plan. Every service rendered is weighed
in units and each service or operation given
a certain weight. Administrative and
agency (hospital, laboratory, x-ray, ambu-
lance) services are paid first and have al-
ways received a full 100 per cent despite
the fact that hospitals and laboratories
have all increased their rates. The re-
maining money is distributed on a unit ba-
sis to doctors, whose services comprise by
far the greatest portion of all medical
costs.

In agreeing to participate in the Health
Service System, the doctors recognized the
experimental nature of the plan. They
realized that it was impossible to antici-
pate exact medical needs. For that reason,
and to protect the System to some extent
against the effect of an epidemic or catas-
trophe, the unit method of payment for
professional services was adopted. This
permits an inadequacy of funds during any
period to reduce the amount paid for in-
dividual services to a point where all serv-
ices rendered will be covered by the monies
available. During the formative period of
the Health Service System, at various times
doctors did not receive a full 100 per cent
for services rendered. However, the value
of the unit has remained at $1.00 since it
was attained in December, 1942, and pres-
ent conditions, in the light of past experi-
ence, would indicate that the System can
continue to pay for professional services in
full at the present rates of contribution,
if the extent of coverage remains substan-
tially the same. The ability of the System
to pay in full for services rendered to mem-
bers has removed one of the greatest diffi-
culties under which the System functioned
during its earlier years.

CHILD HEALTH

Child Health and Welfare agencies must
have as objectives more than the preven-
tion and care of disease. Social and phys-

Weinstein — Pediatric Gynecology

495

ical environment for the full development
of body and mind and opportunity for
wholesome emotional expression must be
provided.

The child’s own parents are provided by
nature to assure him such care, under-
standing, guidance, and protection as will
further his full development. The parents
in turn depend on the social and health
conditions of the society in which they live.
We know, however, that often the child has
lost his parents, or for one reason or anoth-
er, they are inadequate to care for him;
hence the natural family care and protec-
tion are gone.

Also it is too often true that community
health programs are completely lacking or
of such low level that health and well-being
of children suffer.

It is for these reasons, among others,
that governmental responsibility for health
of the child and mother is increasing. Just
glance statistically and comparatively; —
in 1942 the infant mortality rate in the
United States was white 37.3 per 1000 live
births, while the negro rate was 64.2; the
maternal mortality in white 2.2 and negro
5.5. We can hope and expect to see in the
next few years on national levels, state or
local, developments such as greater use by
government of trained health workers —
doctors, nurses, dentists, psychologists —
for protecting and improving child and
mother health, also training teachers for
health education in the class room.

Professional workers in the field of pub-
lic health in the democratic post-war world
must ever bear in mind the importance of
public support for health programs. Such
support is derived from understanding
and thus health education becomes a two
edged sword — it makes the individual put
hygiene into personal practice and it in-
sures public support of public health pro-
grams. The best time for teaching health
principles is during the formative years —
to the school child. A well conceived and
executed health education program in the
grade schools is of primary importance.

The field of' Child Health is wide — too
wide to cover here even in outline. There

are factors very important to the health
and development of children and these
should be mentioned briefly: (1) the eco-
nomic welfare of the people as a whole;
(2) infant welfare facilities, such as well
baby conferences, immunizations and so on ;
and (3) the place of women in industry.
Though obvious, it is well again to empha-
size the favorable effects of good standards
of living on child health, morbidity, and
mortality. The problem of mothers in in-
dustry has been sharply called to our at-
tention during this present war. If, post-
war, women will continue to work outside
their homes, substitutes for home care on
a community basis must be provided for
children. It is not a question of “should”
women work outside the home — it is a far
more complex social problem than that.
From the standpoint of child health in a
post-war world, this question becomes im-
portant.

In the last year of his life, after a
truly international career, Dr. William Os-
ier declared that the future of medical prac-
tice lay in the preservation of health — the
prevention of disease. Public health ad-
ministration, however, is a merciless mas-
ter. It has to get things done ; it gives no
heed to abstract thinking.

SUMMARY

Good health, especially in times of war,
is a prerequisite for work; for happiness;
the absolute safeguard of the intellect ; pre-
serves morality; and is the greatest asset
of family, community and country.
o

SOME PROBLEMS OF PEDIATRIC
GYNECOLOGY*

B. BERNARD WEINSTEIN, M. D.f
New Orleans

This subject has long been neglected by
both gynecologists and pediatricians. It
has only come to the fore in the past decade
and more particularly in the past few

*Presented at the Post Graduate Week in Pedi-
atrics, Tulane University of Louisiana, December
12, 1944.

tFrom the Departments of Gross Anatomy and
Gynecology, School of Medicine, Tulane University.

496

Weinstein — Pediatric Gynecology

years. Two excellent symposia on prob-
lems of adolescence have been held recently
by the American Academy of Pediatrics
and have focused attention on this neglect-
ed field. That one does not think concur-
rently of pediatrics and gynecology is quite
understandable, especially as applied to the
infant and child, but it is difficult to un-
derstand and appreciate the equally neg-
lected adolescent girl, who is rightfully the
concern primarily of the pediatrician who
has known her and followed her progress
for years.

In general, except for injuries and dis-
eases incident to childbearing or senility,
the female under the pediatrician’s super-
vision is heir to practically every gynecol-
ogic disorder which may be found in the
adult. It is important, therefore, that
thorough inspection of the genital tract be
a routine portion of a general examination
of girls, and the sacred taboo of “navel to
knee” be discarded. It is true that exami-
nation does not often yield pathologic find-
ings, but that is no excuse for neglecting
an important part of the examination; it is
astounding how frequently minor patho-
logic conditions such as phimosis, smegma,
and adherent labia are discovered. All
pediatricians are impressed with the neces-
sity of examining the genitalia of the male
child ; it is hoped that this same conscious-
ness will follow for the female. The charge
that such examinations are painful and
shocking need not hold, if they are prop-
erly done; it is important that both moth-
ers and children be taught early to be less
selfconscious and less resitant to proper
examination. A woman of thirty years
with an improper background can also be
severely shocked by pelvic examination,
but we do not hesitate to complete an in-
vestigation so important to her health and
well-being.

The technic of examination, gentleness
and cooperation of parent and patient will
of course play a large part in success of
the procedure. The examination should in-
clude, as a minimum:

1. Careful inspection of the external gen-
italia. Note any gross external anomalies

of genitalia, anus, and adjacent areas; evi-
dence of trauma or injury, skin lesions, ac-
cumulations of smegma which may be
causing discharge and local irritation ; evi-
dences of hermaphrodism or pseudoher-
maphrodism ; bulging or imperforate \y-
men.

2. Gentle but thorough recto-abdominal
examination. Presence of hematocolpos or
hematometrium ; displacements and motility
of the uterus; pelvic tumors (uterine, tu-
bal, ovarian, extragenital).

For vaginal smears, often a necessary
part of the examination, one should use a
tightly wound cotton applicator. It should
be gently introduced about one-third of in-
tended insertion distance; if then released,
it will assume a different angle, and with
gentle pressure will glide easily up to the
cervix. Smears made for gonococcus should
always be vaginal and not merely vulval.

SOME ANATOMIC PECULIARITIES OF THE GENITAL
TRACT OF THE YOUNG FEMALE

It is important to review some details
of anatomic and physiologic peculiarities
of an immature genital system, since these
differ so much from the adult and account
for tremendous differences in response to
infection. These differences are not gen-
erally appreciated and are worthy of con-
sideration. The immature vulva is situ-
ated more anteriorly ; the protection af-
forded by the padding of the adult labia
and mons is lacking; the vaginal orifice is
much less recessed, lacking the protection
of pubic hair; the anal and vaginal aper-
tures are more closely approximated. These
factors, plus marked activity, careless hab-
its, and relative uncleanliness contribute to
increased incidence of infections in this
area. Likewise, the anatomy of Bartholin’s
gland differs from the adult, a simple
structure with a poorly developed glandular
epithelium, and are rarely involved in vul-
vovaginal infections. The immature ure-
thra has stratified squamous epithelium in
its anterior two-thirds and transitional
epithelium in its posterior third. Scattered
throughout its length are mucous glands
which may be comparable to Littre glands
of the male. These glands are usually rudi-

Weinstein — Pediatric Gynecology

497

mentary, and urethritis is rarely a primary
infection, though it may occur secondary to
vaginitis. The ducts of Skene’s glands open
into the urethra near its meatus and rarely
become infected.

The vagina of the infant has an alkaline
pH, ranging between 7 and 7.5. Its epi-
thelium is quite thin, containing about 6-12
cell-layers. This thin, uncornified epithe-
lium serves as an excellent medium for gon-
orrheal infection and contrasts with the
squamous epithelium of the cervix, which
is immune to gonorrheal infection in the
infant. Extension of this squamous epi-
thelium into the endocervix to some extent,
and the rudimentary character of the gland-
ular structure of the endocervix also con-
tribute to its immunity from gonorrheal
infection. This is the exact reverse of the
adult situation, where the vaginal mucosa
is cornified, 28-30 cell-layers thick, has an
acid pH (4.5), and is immune to Neisserian
infection, while the cervix and endocervix
are common loci. The pH of the vagina is
important in relation to infection ; gonococci
thrive in slightly alkaline media, but will
rarely persist where the pH is acid. These
considerations form the basis for use of
estrogen therapy in infantile gonorrheal
vulvovaginitis. All vaginitis is dependent
upon these factors of type of vaginal epi-
thelium, vaginal pH, and gylcogen content
of its cells. Use of a chemical paper (ni-
trazine or litmus) to note the vaginal pH
should be routine and a valuable portion of
the pelvic examination.

The uterus is small ; the* cervix has a
squamous epithelium, and the endocervix
has few glandular elements ; the uterine
and tubal canals are extremely narrow.
These factors are important in an appre-
ciation of limitations in spread of infections
upward, and helps to account for rarity of
pelvic inflammatory disease in young girls.
The small ovary, the fact that ovulation
does not occur, to produce a ruptured area
filled with blood (corpus hemorrhagicum)
and form a fine culture medium for organ-
isms, similarly helps to explain the relative
immunity of the ovary.

With these considerations in mind, let us

consider some of the problems of pediatric
gynecology from without inward, ascending
the genital tract.

VULVAL DISEASES

The pediatrician undoubtedly sees a
large number of vulval lesions. Very often
the cause is easily discernible and only rare-
ly is diagnosis difficult; trauma and injury
are common. Edema, hematoma, or hemor-
rhage often seen following trauma, may ap-
pear alarming but usually yield readily to
compression, and hot or cold applications.
Only occasionally is surgical intervention
necessary to suture a bleeding area or to
incise and drain a secondarily infected
hematoma. The vulvovaginal region is ex-
tremely vascular, which contributes to the
seemingly massive hemorrhages from rela-
tively minor injuries as well as to resist-
ance to infection and rapidity of healing of
these parts. The medico-legal aspects of
trauma incident to rape or attempted rape
are well known. The vulva may present all
types of skin lesions, both local and general ;
the role of irritating garments, medica-
tions, powders, and allergens must be con-
sidered. Ulcerative lesions of tuberculosis,
syphilis, Ducrey infections, and granuloma
inguinale are fortunately rare. Carcinoma
in this region is extremely unusual at this
age. The diagnosis usually results from
maintaining an open mind, an observant at-
titude, and doing a smear or biopsy on sus-
picion.

THE VAGINA

The vagina is a frequent site of diffi-
culties. Introduction of foreign bodies,
leading to chronic vaginitis with foul dis-
charge, is not uncommon. Frequent errors
in diagnosis provoked by foreign bodies oc-
cur and are largely caused by lack of sus-
picion or inadequate examination. Any or
all vaginal discharges should be suspected.
Of course, many mothers make a great “to-
do” over an occasional clear mucous dis-
charge, which may or may not be noted on
examination. In this case, simple hygienic
measures should be tried before extensive
examination or unwarranted therapy is em-
ployed. Clear mucous discharges are not
infrequently associated with hypothyroid-

498

Weinstein — Pediatric Gynecology

ism and may yield readily to thyroid ther-
apy. The patient with a purulent or bloody
discharge, however, merits careful inves-
tigation. Monilia and trichomonas infec-
tions are rarely seen; the majority of vagi-
nitis cases in children are caused by foreign
bodies, non-specific infection (streptococ-
cus, colon bacillus, staphylococcus, pneu-
mococcus, occasionally diphtheria) and gon-
orrheal infections. Therapy for foreign
bodies is obvious; removal of the foreign
body and use of measures to clear up sec-
ondary infections. Non-specific infections
respond well to hygiene, topical applica-
tions of mild silver solution, or sulfona-
mides.

Therapy of gonorrheal vulvovaginits is
still widely debated. Fortunately, topical
medication in the form of silver irrigations
and applications is largely passe. The
quarrel is between those who lean toward
use of sulfonamides or penicillin,* and
those who prefer estrogens. Excellent re-
sults, up to 95 per cent cures, have been
reported by capable investigators using
either method. In general, sulfathiazole
seems to be the sulfonamide of choice. Oral
use of stilbestrol also yields excellent re-
sults and has an advantage over natural
estrogens in that it may be administered
orally rather than by hypodermic injection
or vaginal suppository. The drug is cheap,
effective, and can be given in milk or
orange juice without the child’s knowledge.
Occasionally side effects to estrogenic ther-
aply occur but are rarely serious. Devel-
opment of the breasts, and other secondary
sexual characteristics, and withdrawal
bleeding have been observed. All of these
are transitory. A far more serious con-
sideration is whether or not estrogenic
therapy significantly deranges glandular
physiology. I do not know. My opinion
is to the contrary. Regardless of the ther-
apy employed, I would like to emphasize

*Some excellent results have been reported with
penicillin, cures being effected with the use of 15,-
000 Oxford units every three hours until 120,000
units are given. Not a large enough series of
cases has been followed yet to report more fully
on this method.

that diagnosis should be made only after
proper smears and cultures have been ex-
amined. With improved methods now
available, this is a relatively simple pro-
cedure. Equal caution should be taken
in pronouncing a “cure.” This should not
be claimed until smears and cultures are
repeatedly negative after discontinuance of
therapy. Authorities differ on how long
a period should elapse before repeated neg-
ative cultures mean “cure.” If after ther-
apy cultures taken at weekly intervals for
a month, then at monthly intervals for
three months, remain negative, we feel that
the patient is cured.

UTERUS

The cervix is rarely a source of difficul-
ties in the immature girl. Downgrowths of
endocervical epithelium onto the external
cervix are very often seen. These ectro-
pions usually disappear spontaneously
within the first year of life. Where they
are persistent and provoke a discharge,
they may be effectively treated with topical
(endoscopic) application of 5 per cent sil-
ver nitrate solution. Rare instances of
carcinoma, of the cervix have been reported.
Stenosis of the cervix associated with hema-
tometrium or dysmenorrhea must occasion-
ally be considered, and patency of the cer-
vix should be determined for such indica-
tions.

The uterus, except for rare benign or
malignant tumors, is seldom a source of
difficulty in the young. In the adolescent
we are concerned with the uterus in rela-
tion to menstrual irregularities and dys-
menorrhea. The latter may occasionally be
associated with acute flexion of the uterus.

THE ADNEXAE

The tubes, probably because of their nar-
row lumina and the protective mechanisms
in the lower genital tract, are rarely in-
volved; occasional instances of hematosal-
pinx and pyosalpinx may be associated with
a stricture of the cervix and retained men-
ses. Tuberculous salpingitis is usually as-
sociated with pulmonary or pelvic tubercu-
losis. After the menarche, the tubes may be
afflicted with any disease found in the ma-

Weinstein — Pediatric Gynecology

499

ture female and of course provoke the same
symptomatology.

The ovaries, prior to ovulation, are rare-
ly the site of infection. The unbroken peri-
toneal covering offers some immunity.
They usually concern us in the child only
as the site for benign or malignant tumors.
The occasional granulosa cell tumor femini-
zation is often dramatic and has been ade-
quately emphasized.

PELVIC PERITONITIS

The pathogenic bacteria are usually
pneumococcus, gonococcus colon bacillus,
streptococcus, staphylococcus, and occasion-
ally tuberculous. Pelvic peritonitis is in-
frequent in the youthful female and is
often difficult to diagnose. It is apt to be
confused with or secondary to some other
acute abdominal condition, such as acute
appendicitis, ruptured appendix, Meckel’s
diverticulitis, mesenteric lymphadenitis,
iliac adenitis. The history is of great value.
We see occasional cases of pneumococcal
peritonitis. A history of recent pneumonia,
preceding abdominal complaints and vulvo-
vaginal infection, frequently aids in diagno-
sis. Routine laboratory studies add little.
There is usually an elevated white count
and variable slight changes in sedimenta-
tion rate. A careful history, physical ex-
amination, and thoughtful differential diag-
nosis is most important. In the young, in-
fection has a tendency to localize with ab-
scess formation rather than to become gen-
eralized. Intelligent use of blood, plasma,
fluid, sulfonamides, and penicillin has -im-
proved the previously serious prognosis for
pelvic peritonitis.

MENSTRUAL DISORDERS

The age at which the menarche appears
varies widely. In the northern United
States it is about fourteen years (twelve to
fifteen), and here in the South it usually
occurs a little later, contrary to prevailing
opinions. While the onset of menses before
the twelfth year is usually considered “pre-
cocious,” it would seem more sensible to
use the tenth year for such designation.
Similarly, menarche after fifteen is usually
considered evidence of delayed development
and failure of the menarche to occur by the

seventeenth year is considered an adequate
basis for diagnosis of primary amenorrhea.
One cannot be too arbitrary about these
ages. A family history of similar varia-
tions in menarche is often very reassuring
to all concerned.

Although precocious puberty has been re-
ported in infants and toddlers, most of
these cases are noted in middle childhood,
around the seventh year. While neoplasm
or hyperplasia of ovarian, pituitary, pineal,
or adrenal glands must be carefully con-
sidered and studied, it can be definitely
stated that most of these cases are entirely
functional with no such lesion demonstrable.
The younger the child, the more seriously
must one consider the probability of malig-
nant disease. In the study of such cases,
examination of vaginal smears is most help-
ful and practical. Urinary hormone assays
are not readily available and must be inter-
preted with caution; enough factual data
have not been accumulated to make them
entirely trustworthy. Other evidences of
accelerated development should be sought
for; “symmetrical precocity” is most apt
to be on a benign, functional basis. Uterine
bleeding in a child is almost never caused
by adrenal hyperplasia or tumor. Very oc-
casionally, careful study will justify ex-
ploratory laparotomy, particularly for
granulosa Cell tumor of the ovary. Of
greater importance for these cases of un-
usual precocity is need for sex education,
protection, and careful psychologic adjust-
ment.

Frequent and difficult problems arise in
management of primary or secondary
amenorrhea, oligomenorrhea, or infrequent
menstruation. When these occur because
of gonadal hypofunction, there should of
course be other evidences of delayed de-
velopment of secondary sex characteristics.
While thyroid extract is frequently useful
in such cases, it is far too often used indis-
criminately for adolescents; one should
always justify this type of therapy by well
known criteria. Endometrial biopsy, hor-
mone assay, and vaginal smear may furnish
valuable diagnostic information; of these
three, the latter is simplest, most practical.

500

Weinstein — Pediatric Gynecology

and quite easy to interpret with a little
practice. By vaginal smear, one should
differentiate the following :

1. Atrophic appearance of smear, indi-
cating absence of estrogenic stimulation.
This is noted in many cases of true pri-
mary amenorrhea and also in some secon-
dary cases.

2. Subnormal estrogenic response and
acyclic features, frequently noted with sec-
ondary amenorrhea.

3. Irregular cyclic changes associated
with irregular ovulation, delayed puberty,
secondary amenorrhea.

Patients having poorly developed sex
characteristics and atrophic vaginal smears
have a poor prognosis. Those who are rel-
atively well developed and exhibit the sec-
ond or third type of smear have a fairly
good prognosis. Those with the third type
and normal development seldom require
treatment, and then the use of thyroid
gives the best results.

It is often difficult to manage these
cases. While increased gonadotropic or
androgenic excretion with virilistic tend-
encies may indicate organic pathology,
these are usually lacking. Here, too, the-
rapy with thyroid extract is often indis-
criminately used ; it should be reserved for
those cases which present objective evi-
dences of hypothyroidism. Constitutional
causes, such as fatigue, poor diet, secondary
anemia or chronic disease are frequently
overlooked. All too commonly pregnancy
is found responsible for amenorrhea in
young girls.

Estrogen therapy is helpful in some pa-
tients who have infantile internal genitalia
and delayed sexual development. Justifi-
cation for this is debated because of asso-
ciated depressant effects on ovarian func-
tion ; certainly estrogens should never be
used over a period of longer than three or
four months without a rest period of about
the same duration. Estrogen therapy may
occasionally improve the emotional status
of the patient by accelerating development
of secondary sexual characteristics and
uterine bleeding but offers little else. The
uterine bleeding is an anovular type from

a proliferative endometrium, and its signif-
icance should be stressed to the parent and
patient. Perhaps more physiologic is use
of cyclic sterol therapy with estrogens
during the first part of the cycle, followed
in the second part with progesterone. This
also has depressant effect on ovarian func-
tion and also requires adequate rest periods.
In spite of glowing reports concerning the
ovarian stimulating effect of gonadotro-
pins, we have seen only poor results.
Cyclic gonadotropins, are still in an experi-
mental stage clinically. General sympto-
matic measures — exercise, rest, and proper
diet — together with occasional use of thy-
roid extract, and judicious estrogenic, or
cyclic sterol therapy remain most useful
and practical.

M EXO METRORRHAGIA

Acyclic or functional uterine bleeding
may be serious and quite alarming. Im-
mediate control is best secured with com-
plete rest, sedation, supportive measures as
necessary for excessive blood loss, oxytocics
and vaginal packs. Excellent results have
been observed with large doses of estro-
gens given intramuscularly or into the
uterine cervix. We have used stilbestrol in
doses of from 5 to 100 milligrams intra-
muscularly in the buttock every four hours.
The same drug can be given orally in doses
of 5 milligrams every three hours until
bleeding stops. I do not like to use male
sex hormone which is contraphysiologic,
but it has been used in doses of 25 milli-
grams intramuscularly at four hour inter-
vals. A cumulative dosage of 600 milli-
grams should not be exceeded, and patient
or parent should be warned to expect mas-
culinizing features, particularly hirsutism.
Simple diagnostic curettage is of course the
time-honored, frequently effective proce-
dure. X-ray or radium is indiscriminately
employed in these young girls altogether
too often and is mentioned here only to be
condemned.

After control of the bleeding episode
and correction of contributory factors in
diet, environment, or emotional disturb-
ances, we have used thyroid, usually with
cyclic sterol therapy, as follows: 0.5 mg.

McHardy and Browne — Gall Stone Ileus

501

stilbestrol daily for 21 days, together with
thyroid extract as specifically indicated.
On the fourteenth day a daily dose of 5
milligrams of corpus luteum is added, and
continued for the next 14 days. In this
way there is an “overlap” of one week
during which both estrogen and progester-
one are given. A.P.L. substance (chorionic
gonadotropin) has been successful occasion-
ally when used in the last half of the cycle,
or for a day or two before and two days
after the onset of the menses. With the
use of 5 to 25 mg. male hormone adminis-
tered orally two or three times a week
throughout, the cycle has been reported to
give good results. I have not used it for
the reasons previously mentioned.

DYSMENORRHEA

Frequency of functional, environmental,
or psychic basis for this most distressing
symptom is well known. Patients com-
plaining of dysmenorrhea certainly deserve
a most careful investigation and early cor-
rection of all possible contributory factors :
physical, physiologic, environmental, diet-
ary and psychogenic. Stenosis of the cer-
vix is often overlooked as a cause, and
sometimes other pelvic abnormalities can
be discovered. In the light of our present
knowledge, however, most cases of dysmen-
orrhea in young subjects must still be
classified as “primary” or “essential.” In
symptomatic management, antispasmodics,
sedatives, and psychotherapy all have their
place. Thyroid extract is often valuable
but is certainly overworked for this, as it
is for some of the conditions previously
discussed. Various endocrine preparations
used in treating cases of dysmenorrhea find
little support in conscientious clinical ob-
servations. Knowing that dysmenorrhea is
present usually only when oyulation has
occurred, cyclic sterol therapy to produce
an anovulatory (painless) period may oc-
casionally be justified. Even temporary
relief from this terrifying pain may do a
great deal to improve the physical, mental,
and emotional status of the patient; we are
often surprised to find that such a pro-
cedure, designed for temporary relief, pro-
duces gratifying permanent improvement.

Again it should be emphasized that such
cyclic therapy should not be used continu-
ously for more than about four months.
Oral corpus luteum, given for the last two
weeks of the period, is frequently valuable.
Further considerations in gynecologic man-
agement of dysmenorrhea are beyond the
present discussion.

SUMMARY

It is hoped that this brief review, which
has only scratched the surface of a fasci-
nating and fertile field for productive in-
vestigation, will stimulate closer coopera-
tion of all concerned with the welfare of
children and adolescents.

o

GALL STONE ILEUS

GORDON McHARDY, M. D.f
and

DONOVAN C. BROWNE, M. D.f
New Orleans

The report of a single incidence of gall
stone ileus is seemingly not justified in
view of the adequate coverage of the sub-
ject in previous publications. However,
because of more frequent early operation
in acute cholecystitis, this entity is one dis-
ease rapidly becoming a rarity. In 1925
Moore1 gave an estimate of four hundred
reported cases ; in the intervening interval
hundreds of additional case studies have
been published. Three relatively recent re-
views of the subject, by Balch2 encompass-
ing ten instances, by Wakefield3 with ten
Mayo cases, and by Hinchey4 with six
cases, thoroughly evaluate the entity. The
virtues of this case report are embodied in
its adherence to the classical clinical pic-
ture, the roentgen preoperative diagnosis
and the completeness of the study.

CASE REPORT

Mrs. M. T., a 53 year old Yugoslavian, was ad-
mitted to Touro Infirmary on October 23, 1943,
with acute abdominal manifestations of ten days’
duration. There was a history of long-standing
biliary tract disease without roentgen evaluation,
a fairly definite bout of acute cholecystitis four
months previous which subsided spontaneously. Six

tFrom the Department of Medicine, Tulane
University School of Medicine and the Gastro-
enterology Department of Touro Infirmary.

502

McHardy and Browne — Gall Stone Ileus

days before admission the patient had a bout diag-
nosed acute cholecystitis by her local physician,
operation had been refused: fever, chills, and right
upper abdominal rigidity had persisted. Twenty-
four hours after admission, the upper abdominal
symptoms suddenly subsided and within eight hours
the patient developed localized pain in the subum-
bilical region with early evidence of high obstruc-
tion. Within twelve hours emesis became fecal;
an upright film of the abdomen was diagnosed
“gall stone ileus” by Dr. M. Teitlebaum.

DISCUSSION

Eriefly surveying the literature one finds
this entity more common in females by a
ratio of 5 :1 with an average age occurrence
of 66 years.2' 5 The history frequently ex-
hibits chronic biliary symptoms upon which
is superimposed acute cholecystitis after
which, during a very variable period from
hours to years, migratory obstructive mani-
festations (partial, intermittent or com-
plete) may develop.

Lowman and Wissing0 report the preop-
erative roentgen diagnosis to have been re-
corded in only eleven instances. The most
typical findings would be those illustrated
in our report; that is, (1) the biliary radi-

cles outlined by the presence of gas within
the ducts; (2) evidence of small bowel ob-
struction; (3) a demonstrable calculus in
the lower ileum. Borman and Rigler5 sug-
gested the roentgen visualization of gas
filled bile radicles as being diagnostic.

The mention in the literature of barium
delineation of the fistula as diagnostic is to
be criticized in view of the dangers of
barium ingestion in the presence of intesti-
nal obstruction ; occasionally elective in-
stances may indicate such.

The management is proximal ileotomy
with removal of the calculus. The mor-
tality reports vary from 10 per cent by
Turner7 to 89 per cent by Moller8 with an
average of 50 per cent.4 This seems unduly
high and is not likely due to delay because
of diagnostic indecision and the age of the
patients which, as previously noted, aver-
ages 66 years.

The resultant cholecysto-enteric fistulas
have been hypothesized to result from a
combination of acute cholecystitis and
choledocholithiasis. The site of the fistulas

Figure 1 Rives ; the longitudinal ileotomy was sutured trans-

Proximal ileotomy with removal of the obstruc- versely. The postoperative roentgen study re-
tive calculus (5x4 cm.) was performed by Dr. J. D. vealed the cholecystoduodenal fistula as illustrated.

D’Ingianni — Intestinal Obstruction

503

Figure 2

The management of the biliary fistula became a
separate problem in ensuing months. Twelve
months subsequent, persistent cholangitic symp-
toms of intermittent fever with chills and emesis
indicated cholecystectomy with closure of the chole-
cytoduodenal fistula. Exploration in the common
duct revealed no dilatation and no calculi; common
duct drainage was instituted.

Pathologic study of the removed gallbladder re-
vealed no finding of significance.

The patient is now asymptomatic.

is most frequently cholecystoduodenal (57
per cent), cholecystocolic represent 18 per
cent and cholecystogastric are least fre-
quent (4 per cent). Multiple involvement
occurred in eleven of the Mayo Clinic 176
cases.3

It is generally conceded that immediate
surgical attack upon the fistula is contrain-
dicated. Elective correction is usually not
favored for it is proved that many fistulas
close spontaneously. However, for specific
indications such as existed in our case, that
is, evidence of persistent fistula and mani-
festations of recurrent cholangitis, surgical
management is 'imperative provided the
risk is not prohibitive.

SUMMARY

An interesting illustrative case is pre-
sented of gall stone ileus in which a roent-
gen preoperative diagnosis permitted sur-
gical relief of obstruction and subsequently
evaluated persistent cholecystoduodenal
fistula as the source of ascending cholangi-
tis and indicated corrective operation.

REFERENCES

1. Moore, G. A. : Gall stone ileus, Boston M. & S. J.,
192 :1051, 1925.

2. Batch, F. G., Jr. : Gall stone ileus, New England J.
M., 218 :457, 1938.

3. Wakefield, E. G., Vickers, F. M., and Walters, W. :
Gall stones causing intestinal obstruction, Surgery, 5 :670,
1939.

4. Hinchey, P. R. : Gall stone ileus, Arch, Surg., 46 :9,
1943.

5. Borman, C. N., and Rigler, L. G. : Spontaneous in-
ternal biliary fistula and gall stone obstruction, with par-
ticular reference to roentgenologi-c diagnosis, Surgery,
1 :349, 1937.

6. Lowman. R. M., and Wissing, E. G. : Preoperative
roentgen diagnosis of gall stone ileus, J.A.M.A., 112 :2247,
1939.

7. Turner, G. G. : A giant gall stone impacted in the
colon and causing acute obstruction, Brit. J. Surg., 20 :26,
1932.

8. Holier, cited by Moore.

0

INTESTINAL OBSTRUCTION FOLLOW-
ING THE USE OF COTTON

REPORT OF TWO CASES

VINCENTE DTNGIANNI, M. D.

New Orleans

Recently I reported a case of intestinal
obstruction following the use of cotton su-
ture material, pointing out how easily one
might permit a piece of waste to remain
or find its way into the abdomen. Before
this case report was actually published an-
other similar case presented itself. This
double occurrence in rapid succession under
the supervision of one surgeon may be high-
ly coincidental and rare; however, the fact
that these cases did occur emphasizes the
great danger of carelessness in the use of
cotton.

One need never worry about this act of
carelessness when using chromic, for in
three or four days the material is absorbed.
Chromic promotes a polymorphic leukocytic
reaction which disintegrates the material.
Cotton, on the other hand, promotes fibro-
sis, a proliferation of fibroblasts, which en-
capsulates the material and through its con-

504

Burch and Dunlap — Clinico-Pathologic Conference

traction tends to constrict the tissue in its
vicinity.

If this catastrophy, intestinal obstruc-
tion, continues to occur it will become a
most serious contraindication to the use of
cotton suture material within the abdomen.
Mindful of this possible complication, I
have largely discontinued the use of cot-
ton within the abdomen, although I still use
it exclusively in the fascia, for I believe
that cotton material is unexcelled in this
particular phase of surgery.

CASE REPORT NO. 1

I. M., a white female, aged 21, had had an ap-
pendectomy in 1940 and cotton was used in the
procedure. On January 9, 1943, she was taken
with severe abdominal pain and vomiting. The fol-
lowing day she was admitted to the hospital, where
a diagnosis of intestinal obstruction was made,
clinically and roentgenologically. She was pre-
pared for an operation. Inspection of the perito-
neal cavity revealed collapse of the ileum and of
a portion of the jejunum with dilatation above
the constricted area. Exploration of this area
revealed a band circumscribing the gut, the ends
of which attached to the mesentery. When the
band was removed it had the appearance of a
piece of cotton. It was studied microscopically and
verified as such.

CASE REPORT NO. 2

Mrs. L. M., aged 27, a white female, was ad-
mitted with vomiting, distention, and x-ray evi-
dence of intestinal obstruction. She had been
operated upon at another hospital for acute appen-
dicitis in 1942. Her record revealed that she had
been sutured with cotton and had an uneventful
recovery until her present illness. Exploration of
the abdomen through right rectus muscle splitting
incision showed evidence of obstruction. The upper
ileum was constricted by a band which extended
from the mesentery to the opposite side of the
mesentery. It was about five centimeters long.
Recovery was uneventful. The pathologic report
revealed the band to be a fibrosed encapsulated
piece of suture material.

Two such cases occurring in quick suc-
cession lead me to reiterate : when using
cotton, let us be ever mindful of the ex-
cess. Also it might be interesting to ex-
amine more closely the bands we find in
cases of obstruction, for many of them may
be encapsulated non-absorbable suture ma-
terial, left-overs from a previous operation.

BIBLIOGRAPHY

D’Ingianni. V. : Intestinal obstruction following the use
of cotton. New Orleans M. & S. J., 97 :322, 194o.

Meade, Win. H., and Ochsner, A. : The relative value of
catgut, silk, linen, and cotton as suture materials, Sur-
gery, 7 :485, 1 040.

A CLINICO-PATHOLOGIC
CONFERENCE

GEORGE E. BURCH, M. D.f
and

CHARLES E. DUNLAP, M. D.ff
New Orleans

The following is an abstract of the his-
tory of a patient who died in Charity Hos-
pital and who presented a little appreciated
cause for hypertension.

N. H., a colored female aged 34, was admitted
to the hospital on October 20, 1944, with a chief
complaint of “high blood pressure.” She had been
complaining of headaches and spots before her
eyes ever since pregnancy and delivery in June,
1944. She also stated that she had dyspnea on
exertion. For approximately one month prior to
admission she had attended the medical clinic,
where her complaints were the same. In clinic
she had been put on a diet and given some small
white pills for her blood pressure. Her appetite
had been poor for some time. The past history
was essentially negative, except that on June 26,
1944, she was admitted to the obstetrics service in
the seventh month of pregnancy, at which time
the diagnosis of toxemia of pregnancy was made.
She delivered of a stillborn fetus and made an
uneventful recovery.

Physical Examination : The patient was a fairly
well developed and well nourished colored female
who appeared rather drowsy. Blood pressure was
212/140, pulse 100 and respirations 24. The pu-
pils reacted slowly to light; bilateral papilledema
was present. Examination of the heart revealed
the PMI in the sixth interspace in the midclavicu-
lar line. The rhythm was regular; aortic second
and apical sounds were increased. No murmurs
were heard. The liver was palpable two finger
breadths below the right costal margin, and was
tender. No ankle edema was present.

Laboratory Findings: Urine, alkaline; sp.gr.

1.008; albumin 2+; sugar negative; microscopic
negative. Kline negative on October 21, 1944 and
on October 24, 1944. Blood chemistry on October
21, 1944, urea nitrogen 95; creatinine 20.5; on
October 24, 1944, urea nitrogen 154; creatinine
26. Electrocardiogram (in clinic) September 22,
1944, suggestive of left ventricular hypertrophy,
otherwise normal.

Course: The patient was afebrile. She was put
on a salt free diet, absolute bed rest, phenobarbital,
grain V2 three times daily, and was given 3000
c.c. of fluids daily. Urinary output was appar-

fFrom the Department of Medicine, and
ffDepartment of Pathology, Tulane University
School of Medicine, New Orleans, La.

Burch and Dunlap — Clinico-Pathologic Conference

505

ently satisfactory, but was not charted very care-
fully. On October 24, 1944, she became dyspneic,
complained of chest pain, and had an episode of
nose bleed. The dyspnea became worse, and nasal
oxygen was administered. On October 23, 1944-
there were rales in her lungs. She was given
morphine grain one-sixth and started on digitalis.
Her condition continued poor. On October 24 she
began to excrete only very small amounts of urine,
and it was necessary to catheterize her. It was
noted that there was urea frost on her face. On
October 26 she developed Cheyne-Stokes respira-
tion, pulse became largely imperceptible, and the
patient expired.

Dr. Burch: Obviously from the clinical
record, this patient had a disease associated
with hypertension and heart disease with
acute left ventricular congestive heart fail-
ure. In a patient of this age with the data
described above, there are just four disease
states which could explain this picture:

1. Terminal hemorrhagic nephritis;

2. Malignant essential hypertension;

3. Chronic pyelonephritis;

4. Congenital polycystic kidneys.

The data are insufficient to rule in or
out any one of the four conditions with any
degree of certainty. The absence of a defi-
nite history of acute hemorrhagic nephritis
tends to eliminate chronic active hemor-
rhagic Bright’s disease as a diagnosis.

The diagnosis of pyelonephritis is usually
not difficult to make if the patient is prop-
erly studied. Catheterized bladder urine
will show evidence of infection; for exam-
ple, pus cells and bacteria. The bacteria
and white cells indicate pyelitis if found
in urine collected directly from the kidney
pelves. Casts, red cells and impaired renal
function indicate nephritis. This patient
was deprived of these studies.

Essential hypertension could be accepted
as the diagnosis after the other three pos-
sibilities had been eliminated. With prop-
er studies, pyelonephritis and congenital
polycystic kidneys could have been defi-
nitely ruled in or out clinically. With preg-
nancy any type of renal disease is apt to
be exaggerated, although in a recent issue
of the Journal of Clinical Investigation a
study is presented which indicates that
pregnant women get along well in the pres-
ence of glomerulonephritis. Pyelitis is a

very common complication of the later
stages of pregnancy. It is impossible to
learn from the history the time of onset
of the disease responsible for the patient’s
death.

The diagnosis made on the obstetrical
service was toxemia of pregnancy, a vague
and inadequate term in this instance in
view of the progress of the disease with
the resultant death. Obviously, it was not
true eclampsia of pregnancy because, as
we know, if the patient survives the acute
episode, the recovery is said to be com-
plete. This patient had some sort of kidney
disease that was precipitated or exagger-
ated by the last pregnancy. In our colored
medical service we have seen a great num-
ber of patients with pyelonephritis, espec-
ially following pregnancy. Complete clini-
cal surveys are made routinely in most
patients who enter with hypertension; this
includes a good urologic examination. Not
only are the pelves visualized but the func-
tion of each kidney is studied individually.
Frequently the diagnosis of pyelonephritis
follows.

Only a guess can be made as to the cause
of death in this patient. It is impossible
with the data available to make a satis-
factory diagnosis. The patient most like-
ly had pyelonephritis as the primary dis-
ease. Chronic pyelonephritis often pre-
sents a picture identical with that of es-
sential hypertension and chronic hemor-
rhagic Bright’s disease. Pyelonephritis, of
course, has a known cause; the others do
not. In the final stage of old chronic
pyelonephritis, fever may be absent and in-
fection or previous pelvic infection not sus-
pected.

The patient obviously had true uremia.
This physiologic diagnosis is certainly cor-
rect, regardless of the primary underlying
renal disease responsible for the renal
failure.

The heart was diseased. The etiology
was hypertension and nephritis. These fac-
tors damaged the myocardium and the for-
mer added an extra load on the heart. The
patient’s heart was large. The anatomic
change must include cardiac hypertrophy.

506

Burch and Dunlap — Clinico-Pathologic Conference

I do not think there was myocardial infarc-
tion. The physiologic diagnosis was nor-
mal sinus rhythm, and congestive heart
failure, right and left; left,^ because of the
dyspnea and rales in the chest, and right
because of the large liver, probably an ex-
pression of the increase in systemic venous
pressure. The functional state was Class
IV. There must have been a terminal
bronchopneumonia, an entity to be ex-
pected in such patients.

Resident: Would you classify the nephro-
scleroses?

Dr. Burch: If the patient had had un-

complicated kidney damage in association
with essential malignant hypertension, it
would have been malignant nephrosclerosis.
A patient is not considered to have benign
nephrosclerosis and malignant hypertension
simultaneously. These two clinical states
do not occur together. In other words, es-
sential hypertension is associated with
nephrosclerosis as the renal counterpart of
the hypertensive syndrome. Thus:

1. Benign nephrosclerosis is seen in as-
sociation with benign essential hyperten-
sion.

2. Malignant nephrosclerosis is seen in
association with malignant essential hyper-
tension.

Student: What about hypertensive en-
cephalopathy?

Dr. Burch: The patient had papilledema
which is a part of the malignant state of
the hypertension. I do not think a diagno-
sis of hypertensive encephalopathy can be
made since the patient did not have true
eclamptic seizure of a mild or severe sort.
True uremia explains the mental state and
much of the clinical state. Because of the
high blood pressure and eyeground findings
a malignant phase of some type of hyper-
tension was present.

Dr. Platou: What is the frequency of
hypertension with early pyelonephritis in
adults?

Dr. Burch: I do not know, but on our
service it appears that the majority of cases
present hypertension as a part of the pic-
ture.

Dr. Platou: I ask this question because

it has been our observation in children that
hypertension commonly accompanies pyelo-
nephritis.

Dr. Dunlap: Dr. Burch, would you care
to enter your final diagnoses on the black-
board ?

Dr. Burch: Clinical Diagnoses:

I. Chronic pyelonephritis

II. True uremia

III. Heart disease

a) hypertension and nephritis

b) enlargement

c) normal sinus rhythm, conges-

tive heart failure (right and
left)

d) Class IV.

IV. Bronchopneumonia with possible

pulmonary infarcts.

Dr. Dunlap: Could we now have an idea
of the students’ diagnoses on this case?

Dr. Pullen: Malignant nephrosclerosis

17, benign nephrosclerosis five, chronic sep-
ticemia four, toxemia of pregnancy six, es-
sential hypertension 26, and hypertensive
encephalopathy one.

Dr. Dunlap: We do not seem to have
many students agreeing with Dr. Burch.
I would like to begin by complimenting Dr.
Burch on making an anatomic diagnosis.
I have known clinicians who do this rou-
tinely and I consider it an excellent habit.
Modern medicine began when physicians in
general began to take an interest in ana-
tomic diagnoses about the middle of the
last century and encouraged autopsies on
their own patients. I do not think any
physician can hope to treat disease states
successfully unless he has a clear idea of
what he is treating. His mental picture
of the disease should not be limited to path-
ologic anatomy but should include morbid
physiology and chemistry. Dr. Burch has
made such a diagnosis for you. I might
say that his diagnosis is somewhat more
successful than the students’ diagnoses. He
is still ahead of you.

This patient, to begin with, had a big
heart — it weighed 400 grams, and in the
absence of valvular or other lesions, we
consider this very good evidence of hyper-
tension of some standing. The principal

Burch and Dunlap — Clinico-Pathologic Conference

507

enlargement was of the left ventricle, the
ventricle which was pumping against the
high systemic blood pressure. In addition,
the patient had pulmonary edema. Some
regions of pneumonic consolidation were
also found. Microscopically, we found
edema and an early inflammatory exudate
in the alveoli, indicating an early hypo-
static bronchopneumonia. The most im-
portant pathologic change was present in
the kidneys. I hold both of them here.
One weighed 90 grams and the othei
weighed 50 grams or a total of about half
the normal weight of the kidneys. This kid-

Fig. 1. Kidney showing pyelonephritis. Inflam-
matory cells are present infiltrating the interstitial
tissue. The tubules are dilated and hyalin casts
are present in the lumens.

ney, as you will see when I pass it around,
has been reduced to a shell of kidney sub-
stance surrounding a dilated pelvis. The
distance between the tips of the calyces
and the outer surface of the kidney meas-
ures about 2 mm. The dilatation of the pel-

Fig. 2. Kidney: The photograph shows exten-
sive proliferation and thickening of the walls of
small arteries and arterioles. Similar changes are
often seen in benign nephrosclerosis.

vis is sufficient to indicate that pyelo-
nephritis is the probable disorder since
neither nephrosclerosis nor glomerulo-
nephritis produce pelvic dilatation. The
other kidney shows similar changes but not
in such an advanced stage. The capsule
of the kidney was so adherent to the renal
substance that it could not be separated
readily. This is the result of scar forma-
tion in the cortex of the kidney. On these
gross findings alone, Dr. Burch’s diagnosis
of pyelonephritis is well supported. Micro-
scopically, we found some further evidence
in confirmation of this diagnosis which I
will show you in lantern slides.

I might say a few words about the hyper-
tension which was the most striking clini-
cal sign of disease in this patient. The
work of Goldblatt and others who have in-
vestigated the importance of kidney dis-

508

Burch and Dunlap — Clinico-Pathologic Conference

ease as an etiologic factor in hypertension
is sound and valid, but I do not think we
should lose sight of the fact that there
are causes of hypertension other than im-
paired renal circulation. There is, for ex-
ample, an important neurogenic factor in
many cases. In the series of kidney biop-
sies examined by Castleman at the Massa-
chusetts General Hospital, taken from pa-
tients who were subjected to sympathec-
tomy in an attempt to relieve hypertension,
damage of the arterioles of the kidney was
present in most cases, but in seven patients
with established hypertension, no such
changes were found. This certainly sug-
gests that hypertension may occur indepen-
dent of prior organic disease of the renal
arterioles. Even when the arterioles of the
kidney do show hyalin or necrotic changes
it does not necessarily prove that the change
in the kidney vessels came first and caused
the hypertension.

Returning to this particular case, I think
it is very likely that this woman had pyelo-
nephritis during her last pregnancy, and
probably in preceding pregnancies since
the renal changes are old. As Dr. Burch
has told you, pregnancy is a difficult and
dangerous experience for any woman with
kidney disease, since the hazard of acute
complications is increased and pregnancy
may often initiate further kidney damage.
Tyelonephritis is one of the common com-
plications of pregnancy whether or not the
patient had previous kidney disease. Pyelo-
nephritis of pregnancy has been attributed
by some authors to pressure of the enlarged
uterus on the ureters as they cross the pel-
vic brim with resulting obstruction and
infection. Roentgen studies have shown,
however, that dilatation of the ureters
often extends down to the bladder, well
below the probable point of mechanical
compression. More recently it has been
appreciated that there is some degree of
physiological dilatation of the ureters in
almost every pregnancy. They often be-
come as large as a centimeter in diameter.
This is apparently a manifestation of a
decreased tone of smooth muscle through-
out the body during pregnancy which may

also give rise to other clinical manifesta-
tions such as hypotension, biliary stasis
and constipation. As you know, when sta-
sis occurs in the natural channels of the
body, particularly in ducts, it predisposes
to infection. Stasis in the ureters due in
part to mechanical obstruction and in part
to physiologic dilatation is the most prob-
able precipitating cause of the pyelitis of
pregnancy. In a pregnant woman with
kidney disease, pyelonephritis may be sus-
pected but glomerulonephritis and arterio-
lar kidney disease must be ruled out. Acute
pyelonephritis often elevates blood pressure
but after the infection has subsided, we
expect the hypertension to disappear in
whole or in part. Recurrent or progres-
sive pyelonephritis may give rise to a re-
current or permanent hypertension. As Dr.
Burch has pointed out, there is little diffi-
culty in diagnosing acute pyelonephritis.
In the chronic and healed stages, it is not
so easy since the patient may be left with
a great deal of destruction of kidney sub-
stance and loss of many functioning
nephrons but without much active progres-
sive disease in the kidneys. In the absence
of active kidney disease, the urine contains
few abnormal constituents. When an ad-
ded burden is thrown upon such a kidney
the number of functioning nephrons may
be insufficient to clear the blood of the
products of metabolism and uremia may
appear. I think this concept is important.
In the quiescent phases of advanced glom-
erulonephritis, vascular nephritis, or pyelo-
nephritis, one may fail to recognize renal
disease because the urine contains little in
the way of albumin, casts, red ceils or
white cells. At autopsy in such patients,
we find kidney changes such as you see
here, a small shrunken kidney with many
of its functional elements destroyed, but
with little active progressive disease. Al-
bumin, white cells, and red cells appear
only in urine which is being secreted by
nephrons that are diseased. At the time the
kidneys fail the disease may be almost
static, and the failure may be due to the
fact that there are too few nephrons still
functioning to maintain life.

Burch and Dunlap — Clinico-Pathologic Conference

509

Another point I would like to make is
that although various disorders of the kid-
ney may start in a different fashion, as
the disease progresses they approach a final
common path in terms of pathologic
changes. That is, in glomerulonephritis
the initial lesions are confined chiefly to
the glomeruli. However, in the chronic
stages we see not only glomerular changes
but atrophy of tubules and thickening of
the arterioles very similar to that seen in
nephrosclerosis. In like fashion the later
stages of nephrosclerosis are characterized
by changes in the glomeruli and atrophy of
the tubules in addition to the vascular
changes, giving a final picture somewhat
similar to that of long standing glomerulo-
nephritis. Even in pyelonephritis, begin-
ning as an acute bacterial infection of the
kidney, we may see in the later stages
changes in the glomeruli suggestive of
glomerulonephritis and arteriolar damage
suggesting nephrosclerosis. I would like to
show you now some lantern slides prepared
from the kidneys of this patient. You will
see that there are well developed glomeru-
lar, capsular and vascular changes in ad-
dition to the chronic inflammatory lesions
of pyelonephritis.

We have then a case of a woman who
died in the late stages of chronic pyelo-
nephritis with hypertension, cardiac hyper-
trophy, heart failure, terminal uremia, pul-
monary edema, and bronchopneumonia.
The disease can be diagnosed as pyelone-
phritis even though we do see glomeru-
lar and vascular changes in addition to the
characteristic interstitial inflammation and
scarring.

Dr. Burch: There are a few comments I
would like to make ; first, concerning the
terminology used by the students. A com-
mon mistake is made here. The term
“chronic nephritis’' is not complete or pre-

cise enough. “Toxemia of pregnancy” is
another example of vagueness. Express
your diagnosis completely and in good con-
crete terms in order to be clear and precise.

There is a tendency in the handling of
obstetric patients to neglect the postpartal
follow-up. This patient illustrates this er-
ror. If she had been carefully followed
postpartally, it is likely that the pyelo-
nephritis would have been recognized soon
after its onset. All patients should be fol-
lowed after delivery. This should include
a complete periodic health examination
consisting not only of a pelvic examination
but a complete inventory of health for many
years, not for just a short time. If this
patient had been examined carefully post-
partally, the diagnosis would have been es-
tablished. A six weeks’ postpartal study
consisting of one pelvic examination is of
little value. Many complications caused by
or precipitated by pregnancy, could be de-
tected, treated early and properly but only
if patients are followed properly and long
enough. All patients who become pregnant
should see an internist during and after
pregnancy in order to take an inventory of
the effects of pregnancy. A failure to
make use of such examinations is one short-
coming in preventive medicine.

Dr. Dunlap is certainly correct in asking
that every one make a complete diagnosis.
Remember as students of medicine that you
cannot manage a patient properly without
thinking in terms of all phases of his dis-
ease. If you fail to do this, the study is
only superficial and so is his physician in
his thought. Visualize a disease from all
of its expressions, physiologic, chejmical,
pharmacologic, pathologic and so on. All
good physicians do this routinely and
without effort and by all means do not for-
get the psychiatric aspects of all organic
as well as functional diseases.

510

Editorials

NEW ORLEANS

Medical and Surgical Journal

Established, l&UU

Published by the Louisiana State Medical Society
under the jurisdiction of the following named
Journal Committee:

Val H. Fuchs, M. D., Ex officio
For two years: G. C. Anderson, M. D., Chairman
Leon J. Menville, M. D.

For one year: J. K. Howies, M. D., Vice-Chairman
For three years: C. Grenes Cole, M. D., Secretary
E. L. Leckert, M. D.

EDITORIAL STAFF

John H. Musser, M. D Editor-in-Chief

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OUR LATE PRESIDENT

The sudden and unexpected death of
Franklin Delano Roosevelt has had many
repercussions throughout the country. The
great bulk of the American population ap-
parently felt that the death of their Presi-
dent was a real catastrophe. In the troubled
war-time waters that our ship of state is
now navigating, the citizenry sensed that
in Mr. Roosevelt they had a captain who
could best pilot them into the safe harbor
of peace. The immediate reaction to his
death was the feeling that he could not be

replaced. While many citizens did not
agree with Roosevelt’s domestic policies,
they felt that in the field of foreign activi-
ties he was the only real diplomat in the
country; that he alone was familiar with
the chancelleries of Europe and that he
alone was capable of dealing with the dual
masters of international politics, Churchill
and Stalin. Now that some days have
passed since the death of Mr. Roosevelt, the
people are beginning to adjust themselves
to the idea that no man is absolutely indis-
pensable and that always the people of the
United States have had the good fortune
to have some man arise, in times of crisis,
capable of meeting the emergency. The
new President has already been successful
in obtaining from Premier Stalin the as-
signment of Mr. Molotov to the San Fran-
cisco conference, so that it is quite possible
that President Truman will be equally suc-
cessful in international politics, although
accomplishing his purposes by more direct
and blunt methods than Mr. Roosevelt em-
ployed.

At home and in domestic fields Mr.
Roosevelt undoubtedly motivated many of
the semi-socialistic bills which have ap-
peared in Congress which have to do with
the physician. His intimate friendship
with Senator Wagner would certainly con-
firm this statement. His desire to regi-
ment the medical profession was expressed
by him many times, not of course in such
phraseology but at least, by indirection, in-
dicating that the Federal government
should take over the supervision of the
medical care of a very large section of the
general population of the United States.
What Mr. Truman will do about socialized
medicine we cannot tell at the present mo-
ment but undoubtedly there will necessarily
be a great deal of objection in Congress to
any great increase in Federal spending.
Unless pushed by the chief executive of the
country, large expenditures for unproved
socialistic schemes will not be approved by
the Congress in the next few years. This
is said advisedly, as after the war the
United States will have an enormous debt;
the servicing of this debt alone will cost

Editorials

511

more than our yearly expenditures in days
prior to World War II. To fail to reduce
taxes after the war is over will certainly
be an economic error and a bad political
move but if all the schemes for great ex-
penditures of money are to be legislated,
taxes will not be decreased but will have
to be increased.

Although many of us disapproved of the
domestic polities of Mr. Roosevelt, and this
applies not only to the professional man
but to the business man, we cannot but
concede that his conduct of the war has
been carried out with a strong hand, an
intelligent mind and a clear vision. Un-
doubtedly Mr. Roosevelt will be accorded in
history recognition as one of the great
Presidents of this country.

o

JACOB C. GEIGER

The author of the address delivered to
the graduating class of Tulane Medical
School last fall, and published in this num-
ber of the Journal, is a Louisianian who has
made good far from his native state. Dr.
Geiger was born in Alexandria, where
members of his family still reside. He
graduated from Tulane Medical School in
1912 and received the degree of Doctor of
Public Health in 1919. In 1935 he was
given the honorary degree of Doctor of
Science by the Louisiana State University
and in the autumn of 1944, an honorary
Doctor of Laws from Tulane University.

Shortly after graduation, Geiger moved
to California where he became connected
with the California State Board of Health.
He has remained since then on the Pacific
Coast, with the exception of a period of
'four years when he was Assistant Com-
missioner of Health in Chicago. Returning
to San Francisco, he was placed on the
medical faculty of the University of Cali-
fornia as well as Stanford University. For
nearly thirteen years he has been the chief
health officer of the City and County of
San Francisco, with the title of Director
of Public Health. In addition to his public
health responsibilities, he also has under his
jurisdiction the excellent San Francisco

Qity Hospital which is used as a teaching
institution by the two San Francisco med-
ical schools. Besides the honorary degrees
from Louisiana State University and Tu-
lane University, Geiger has been similarly
honored by Santa Clara University and the
Hahneman Medical College. He has been
decorated by the Chilean government, by
the Chinese Government, by the Brazilian
government, and by the government of
Cuba. He has been cited by the govern-
ment of Panama for distinguished and dis-
tinctive service in public health.

It is a pleasure to record the accomplish-
ments of a loyal Louisianian, a physician
who has made a distinct success in his
chosen field of medicine, a man who has
accomplished much, often against strong
political opposition, in making the City of
San Francisco one of the outstandingly well
managed cities of this country from the
broad aspects of public health.

o

THE WATERHOUSE - FRIDERICHSEN
SYNDROME

There has been an ever increasing in-
terest in this syndrome which was first
described by Waterhouse in 1911. The
reason for this acceleration of interest lies
in the fact that there have been an increas-
ing number of cases of meningococcic men-
ingitis all over the United States. While
this syndrome is supposed to occur with
any severe bacteriemia, in the great ma-
jority of cases the meningococcus is the
implicated organism and indeed it may be
that it is the only organism in spite of the
fact that the pneumococcus and H. strepto-
cocci have been inculpated.

D'Agati and Marangoni* report on six
cases that they had the opportunity of ob-
serving in a station hospital. This is a
very large number of cases for any one man
to see and probably explicable on the basis
that these two medical officers had charge
of the meningitis wards, in which instance

* D’Agati, V. C., and Marangoni, B. A.: The
Waterhouse-Friderichsen syndrome, New Eng-land
J. M., 232:1, 1945.

512

Organization Section

they would have the opportunity of seeing
a large number of these cases.

In the past, undoubtedly the Waterhouse-
Friderichsen syndrome has been considered
merely to be a fulminating type of menin-
gitis without recognition of the underlying
pathologic lesions which are represented by
bilateral adrenal hemorrhages and, if the
patient survives 24 hours, increase in the
size of the heart, pleural effusion, severe
hepatic and pronounced renal damage in
the cases with prolonged survival periods.

The clinical features are characterized by
prodromal symptoms similar to any infec-
tion of the upper respiratory tract. The
authors state that the onset of the bacteri-
emia is sudden and dramatic, associated
with a petechial eruption which soon be-
comes purpuric. These hemorrhagic skin
lesions occur all over the body, varying in
size from minute petechiae to large pur-
puric areas. There may be a temporary
delirium but mental clearness is usually
present. The temperature is not unduly
elevated and soon drops to normal. This is
probably evidence of shock. The blood
pressure is extremely low but if the initial
shock is survived, blood pressure figures
may rise to normal. There is an anuria
which again, if the patient survives 24-36
hours, is followed by oliguria. There is an
extremely high polymorpho-leukocytosis
and marked albuminuria. The spinal fluid,
in the six cases reported by these two au-
thors, was negative although the cultures
in three cases were positive for the menin-
gococcus. This is a somewhat different
finding than in the instances of the several
cases observed in New Orleans, in which
the spinal fluid showed an increased cell
count with increased spinal pressure as
well.

The majority of the patients succumb
within 24 hours; occasionally one survives
for 48 hours or longer, and there have been
several patients in whom death did not
occur. Postmortem examinations showed
pleural effusion and pulmonary edema in
every one of the five bodies that came to
autopsy in the present report. The heart
weight varied from 300-590 grams. The
liver was markedly enlarged ; the kidneys
not unduly. In every instance there were
bilateral moderate to severe adrenal hem-
orrhages.

The treatment of this condition is to
overcome shock, toxemia and bacteriemia;
the first by the usual methods of fluid, heat
and plasma; the toxemia, and the bacteri-
emia, is combatted by 100,000 units of anti-
meningococcic serum, plus huge doses of
sulfadiazine. These authors gave five grams
intrayenously at the onset and eight grams
orally followed by large oral doses with a
total of 25-30 grams administered within
the first 24 hours. Most clinicans who
have recognized the Waterhouse-Friderich-
sen syndrome have given adrenal cortical
hormone therapy. While these military
recorders state that its value is question-
able, this is not in accord with the general
ideas about the treatment of the disease.
It would seem logical to give large doses of
the specific adrenal hormone.

While it hardly seems necessary to lay
stress on a syndrome which is apparently
so invariably fatal, if it comes to be gen-
erally recognized undoubtedly there will
be found patients who are not so severely
attacked and if the condition is recognized
the life of that individual may be saved by
very intensive, properly employed therapy.

o

ORGANIZATION SECTION

The Executive Committee dedicates this page to the members of the Louisiana
State Medical Society, feeling that a proper discussion of salient issues will contri-
bute to the understanding and fortification of our Society.

An informed profession should be a wise one.

POSTWAR MEDICAL PLANNING Medical Society, in line with other groups,
Everyone at present is planning for post- is looking forward to assisting their con-
war conditions and the Louisiana State freres who are now working in the armed

Organization Section

513

medical service. It is believed that our
method of handling this problem will af-
fect a great deal the type of medical prac-
tice we will assume in the future. There-
fore this requires serious consideration by
all of us.

Many groups, national, state and local,
are now giving study to this subject. How-
ever we learn from speaking to the medical
men who are already being mustered out
of the service, that nothing material has
been accomplished. There are many plans
but little action, judging from the opinions
given by the discharged veterans.

The State Society, as well as other groups,
is actively taking a hand in trying to solve
this problem and the committee appointed
to consider this would appreciate any sug-
gestions you may have to offer. These
should be sent to our Secretary-Treasurer,
Dr. P. T. Talbot, who will forward them to
the proper individuals for study and action.
All of our members, both in and out of mil-
itary service, have been circularized for in-
formation but, sad to say, many have failed
to answer, making the study unreliable.
However from the answers received we
have some definite conclusions, as follows:

Only 156 out of 622 questionnaries sent
to those in military service were returned.

The greater proportion who answered,
it was noted, want to practice in the larger
communities; only a few in small localities.

Ninety-five per cent of those in service
desire to return to private practice, show-
ing that it will be difficult for the Govern-
ment to give everyone desiring a discharge
at the close of the war an immediate dis-
charge. Only one in the group desires to
remain in public health work which is a
field the Government is trying to popular-
ize at the present time.

Another conclusion which shows the
trend of the medical man of today is the
fact that over two-thirds want to specialize
or return to a specialized practice. The
old-time family doctor apparently is slowly
disappearing.

Again, another observation shows that
about one-half of the doctors desire re-
fresher courses in surgery and internal

medicine, which are the most popular
courses requested. One-fourth desire ob-
stetrics and gynecology and eye, ear, nose
and throat, and the remaining specialties
are requested by the other one-fourth who
replied.

Only one of the group stated he wanted
more internship but two-thirds requested
residencies; the same specialties as men-
tioned before being the predominant ones.
About one-third desire help in obtaining
assistantships in university departments ;
also in the same proportion of popularity
for the specialties as listed above.

Now, let us consider what can be done
to obtain the best results. A committee of
the Orleans Parish Medical Society has
made certain recommendations which have
been approved by that society. This com-
mittee is headed by Dr. Eugene Countiss
who has taken a very great interest in this
matter since the outbreak of the war.
These recommendations are listed below for
the information of other committees in the
state who might care to duplicate and pos-
sibly improve upon this effort in their lo-
cality. If such work is successful, infor-
mation could be made statewide through
the State Society Committee on Postwar
Planning.

Hospitals be notified of returning phy-
sicians — (Superintendents, switchboard
operators and front office employees be
furnished with a list of such physicians.)

Hospital positions — (The Board of Di-
rectors of the Society demand a stand on
residencies from the hospitals of New Or-
leans; also that they write to hospitals
throughout the state regarding vacancies
for interns or residents.)

Office space — (Contact business mana-
gers of office buildings as to available
space; real estate agents, and the Associa-
tion of Commerce regarding small buildings
in business section and around hospitals
that may be used as doctors’ offices.)

Re-circularize the doctors on the home-
front — (Send another questionnaire to the
doctors on the home-front as to the assist-
ance they may render returning doctors,
even on a temporary basis — ask them to

514

Orleans Parish Medical Society

anticipate their being discharged from
service and what their needs would be as
to refresher courses, etc.)

Refresher courses — (Refresher courses
are being offered by L. S. U. and Tulane,
obtain copies of schedules and incorporate
them in a bulletin and send same to the men
in service — let them know what we can of-
fer them ; also in the questionnaire which
is sent to the home-front doctors ascertain
if they will allow a physician to accompany
them on rounds, or to scrub).

List operations — (List operations at vari-
ous hospitals two or three days in advance) .

List clinics (free) and those in charge.

Interviewing committee — (Two men at
a time appointed to serve each day to in-
terview returning doctors, in an effort to
assist them in problems presented by their
return to practice).

Small business committee — (A commit-
tee of Louisiana Bankers Association be
contacted regarding loans to doctors).

The Committee on Postwar Planning of
the State Society has also some recommen-
dations to be considered. These are as
follows :

Arrange a meeting with building man-
agers in each locality to see if locations can
be obtained.

Meet with hospital heads of private in-
stitutions in order to see if more residencies
and refresher courses can be arranged with
such institutions.

Meet with the Director of the Depart-
ment of Institutions to arrange for the

same possibilities and ascertain if some of
the returning men can be given privileges
of the staff, under supervision.

The Deans of both of the medical univer-
sities are most cooperative and intend to
give courses on theory ; short intensive
courses and also longer ones. It will not
be possible to prepare a schedule, however,
until a larger group indicates their desire
to take these courses. It is also planned to
supplement and reactivate men previously
connected with the schools, on their return.

It has been suggested that all attempts
be made to prevent the Government from
destroying medical equipment ; to encourage
postwar activity and sell this material to
returning service men as the surgical com-
panies have no particular interest in this,
or supplies to sell at the present time.

The Secretary-Treasurer of the Society
has information on file as to possible loca-
tions and requests from doctors throughout
the state for assistants.

The Postwar Planning Committee in-
tends to meet quite frequently in an attempt
to follow these suggestions and will wel-
come criticism, particularly constructive,
which the members of the Society may have
to offer. We would suggest that similar
committees be appointed by the parish so-
cieties throughout the state and that their
findings be forwarded to the Secretary-
Treasurer. By such activity our men who
are in military service will know that the
State Medical Society of Louisiana did not
fail them in their absence.

TRANSACTIONS OF ORLEANS PARISH MEDICAL SOCIETY

CALENDAR OF MEETINGS

May 1 Eye, Ear, Nose and Throat Staff, 8 p. m.

May 2 Mercy Hospital Staff, 8 p. m.

May 7 Board of Directors, Orleans Parish
Medical Society, 8 p. m.

May 9 Clinico-pathologic Conference, Marine
Hospital, 7 :30 p. m.

Touro Infirmary Staff, 8 p. m.

Woman’s Auxiliary, Orleans Parish Med-
ical Society, Orleans Club, 3 p. m.

May 10 Clinico-pathologic Conference, Touro In-
firmary, 12 noon.

May 14 Scientific meeting, Orleans Parish Med-
ical Society, 8 p. m.

May 15 Charity Hospital Medical Staff, 8 p. m.
May 16 Charity Hospital Surgical Staff, 8 p. m.
May 18 I. C. R. R. Hospital, 12:30'p. m.

May 21 Hotel Dieu Staff, 8 p. m.

May 22 Baptist Hospital Staff, 8 p. m.

May 23 Clinico-pathologic Conference, Marine
Hospital, 7:30 p. m.

French Hospital Staff, 8 p. m.

May 24 Clinico-pathologic Conference, Touro In-
firmary, 12 noon.

DePaul Sanitarium Staff, 8 p. m.

May 25 L. S. U. Faculty, 8 p. m.

New Orleans Hospital Dispensary for
Women and Children Staff, 8 p. m.

Orleans Parish Medical Society

515

During the month of April the Society held one
scientific meeting. The program which was pre-
sented by members of the Mercy Hospital Staff,
was as follows: Case Report — Rupture of Eth-
moids with Retrobulbar Cellulitis by Dr. H. Ash-
ton Thomas; Case Report — Missed Labor by Dr.
N. J. Tessitore; Evisceration — A Comparative
Study by Dr. Vincente D’lngianni.

The next scientific meeting of the Society will
be held Monday, May 14. The program will be
presented by members of the Charity Hospital
Staff.

NEWS ITEMS

Dr. Clyde Brooks recently resigned as direc-
tor of the department of pharmacology and ex-
perimental therapeutics in the L. S. U. school of
medicine to become dean of Essex College of
Medicine and Surgery, Newark, N. J. The So-
ciety extends to Dr. Brooks its congratulations and
best wishes.

Drs. Donovan C. Browne and George Taquino
recently attended a meeting of the Iberville Par-
ish Medical Society of Plaquemine. Dr. Browne
spoke on Liver Disorders; Dr. Taquino on Sinus
Diseases in Children.

Dr. J. W. Davenport, Jr., spent a week in the
Rh blood testing laboratory with Dr. Philip Le-
vine at the Ortho Research Foundation, Linden,
N. J. While there Dr. Davenport also visited Dr.
A. S. Wiener in his laboratory and blood and
plasma laboratories of the following institutions:
Blood Transfusion Association, New York City;
New York Post-Graduate Medical School and Hos-
pital; and Johns Hopkins Hospital, Baltimore.

Drs. John L. DiLeo and M. L. Michel were re-
cently cei’tified by the American Board of Surgery.

Dr. E. Carroll Faust spoke on Bubonic Plague
in the Western Hemisphere at a meeting of the
History of Medicine Society recently held in the
Tulane student center building.

Dr. Ralph V. Platou spoke on Problems of the
Spastic Child at a meeting of the International
Council for Exceptional Children recently held in
Charity hospital.

Drs. E. F. Salerno and John M. Whitney were
guest speakers at a recent meeting of the Lake-
view Civic and Improvement Association.

Dr. Chester A. Stewart spoke on The Care of
Tuberculosis at a recent meeting of the Crossman
Co-operative meeting.

Dr. George W. McCoy attended a meeting of
the National Foundation for Infantile Paralysis in

New York City, March 13-14. Dr. McCoy also
attended a meeting of the United States Pharma-
copoeial Revision Committee in Washington,
March 16.

RESUMPTION OF PRACTICE
Drs. Ignatius DeMatteo, Chester Fresh and
David Womack.

HOSPITAL NEWS

At the March meeting of the French Hospital
Medical Staff the following officers were elected:
Dr. Lucien C. Delery, chairman; Dr. Nicholas
Chetta, vice-chairman; and Dr. 0. D. Thomas,
secretary-treasurer.

NEWS OF MEMBERS IN MILITARY SERVICE
Lt. Col. Robyn Hardy writes from Belgium —
“It does one’s heart good to know that he is
not forgotten by his friends even though he is
many miles away. We are having quite a war
over here but are now headed for victory. Noth-
ing you can do can compare with the courage of
our boys in the front line. We see them soon
after they are wounded. They are the finest ever.
Don’t let them down.”

Lt. Daniel W. Beacham states that he has ar-
rived with the 231 General Hospital in France,
where it is “cold and muddy.”

RECENT PROMOTIONS
From Lt. Colonel to Colonel: R. H. Turner,
Oscar Blitz and Charles J. Miangolarra.

From Major to Lt. Colonel: Lawrence H. Strug
and J. O. Weilbaecher, Jr.

CALLED TO MILITARY SERVICE
Drs. William L. Bendel, Jr. and George T. Mel-
linger, both intern members of the Society, were
recently placed on the military rolls.

NUTRITION COMMITTEE

This Society appointed, at the request of the
local Office of Price Administration, a Liaison
Committee between this Society and that organi-
zation, for the purpose of consulting with them
in an effort to clarify some of the confusion on
physicians’ prescriptions for additional points for
rationed foods.

There is a certain standard requirement set up
by the Council on Foods and Nutrition, which the
OPA follows, which does not meet the individual
needs of every community. Therefore, it is the
purpose of this medical advisory committee to
give counsel on the exceptions as requested by
the physicians. The OPA is not bound by our
advice, but have certainly shown their willingness
to cooperate in solving our local problems with-
out recourse to regional boards outside this com-
munity.

516

Louisiana State Medical Society News

The committee has encountered difficulty in
evaluating- request because of insufficient data,
and in an effort to facilitate matters, a standard
request blank is to be sent to each physician for
completion when requesting additional points for
rationed foods. This will not only simplify the
physicians’ problem, but will facilitate the work
of this committee. These request blanks will be
available at local War Price and Rationing-
Boards.

There will appear in the Bulletin from time to
time certain broad dietetic standards for your
guidance, which may be helpful in making your
request.

This committee meets twice a month (second
and fourth Thursdays), and will be glad to meet
with any physician having suggestions or to dis-
cuss particular problems arising.

Donovan C. Browne, Chairman.

DePAUL SANITARIUM STAFF MEETING

The following report was received from Dr.
Louis J. Dubos, Secretary:

The regular monthly meeting of the Medical
Staff of DePaul Sanitarium was called to order
at 8:00 p. m. on March 22, 1945, with Drs. Fried-
richs, Holbrook, Watters, Otis, H. Colomb, A.
Colomb, May, Connely, Unsworth, Hill, Thompson,
Anderson and Dubos in attendance.

The scientific part of the program was ushered
in by Dr. Otis presenting the record of a death
of Mrs. E. B., case No. 3572, a dementia precox
patient given insulin shock therapy with resultant
death which was due to acute dilatation of the
heart and edema of the lungs presumably follow-
ing hyper-insulinism. This was the first fatality
occurring at DePaul since shock therapy had been
employed. The case was discussed in detail by
Drs. Holbrook, Dubos, Unsworth and H. Colomb.

Next Dr. Watters gave some progress notes on
case No. 3684 presented at the meeting of Janu-
ary 25, 1945, as one of headache, arriving at the
conclusion that these headaches were probably
due more to an emotional outburst then to mi-
graine. He based his opinion on the fact that
they occurred oftener over the week-end which
she spent with her mother and at which time fre-
quent quarrels led to emotional strain which in-
variably precipitated an attack of headache.

Finally, Dr. Otis presented case No. 3460 as
one of probable precox in a young, married wom-

an, who gave birth to a baby in September, 1944,
followed by blankness, disinterest, muteness and
hysteria. She was given a few electroshock treat-
ments with little result, then later placed on in-
sulin shock therapy, but these had to be discon-
tinued because of a progressive fall in blood pres-
sure beyond the margin of safety. At the pres-
ent time she is again on electroshock treatments
and seems to show some slight improvement. This
case was discussed by Drs. Holbrook, Unsworth,
Watters and Dubos.

When requested by the Chairman to say a few
words, Sister Anne stressed the need of more
autopsies so that our minimum percentage could
be maintained.

Dr. Holbrook suggested that the Sisters en-
deavor to secure autopsies by speaking to the
families as the prognosis became more grave and
in this way gain their consent in advance. Dr.
Holbrook voiced the opinion that the families of
patients should not seek information about any
patient from the hospital personnel but should
contact the physician for such information. Dr.
H. Colomb suggested that the rule of the Institu-
tion henceforth be that no information should be
given over the phone except in cases of emer-
gency and this suggestion seemed acceptable to
all present.

Dr. H. Colomb moved that a committee be ap-
pointed to study a means of presenting to the
medical profession in the State the purposes, prin-
ciples and methods of proper admission of patients
into DePaul so as to avoid later friction with the
families and their physicians. This motion was
seconded by Dr. May and carried, after which the
Chairman appointed Drs. Holbrook and H. Colomb
to serve on this committee.

As several antique mahogany bookcases had
recently been purchased by Sister Anne for the
library, Dr. Holbrook arose and suggested that
the library should be enlarged at DePaul and that
the various staff members contribute toward this
end. Sister Anne said that she would gladly co-
operate by budgeting a fund for this purpose.
Consequently Dr. Holbrook made a motion, sec-
onded by Dr. Otis that a committee be appointed
to study the purchase of new books and periodi-
cals for the formation of a library, which motion
was carried, and the Chairman immediately ap-
pointed Drs. Friedrichs, Anderson and Thompson
to serve on this Committee with Dr. Friedrichs
as Chairman.

O

LOUISIANA STATE MEDICAL SOCIETY NEWS

CALENDAR

Society

East Baton Rouge

Morehouse

Orleans

PARISH AND DISTRICT MEDICAL

Date

Second Wednesday of every month
Second Tuesday of every month
Second Monday of every month

SOCIETY MEETINGS

Place

Baton Rouge
Bastrop
New Orleans

Louisiana State Medical Society News

517

First Thursday of every month Monroe

First Monday of every month Alexandria

First Wednesday of every month
Third Thursday of every month

First Tuesday of every month Shreveport

First Thursday of every month

Ouachita
Rapides
Sabine

Second District
Shreveport
Vernon

SEVENTH DISTRICT MEDICAL SOCIETY

The following officers have been elected by
the Seventh District Medical Society for the year
1945: President, Dr. S. R. Henry, Crowley; Vice-
President, Dr. J. J. Stagg, Jr., Eunice; Secretary-
Treasurer, Dr. Fred C. Winn, Crowley.

o

AMERICAN MEDICAL ASSOCIATION HOUSE
OF DELEGATES MEETING DEFERRED

It was intended that a meeting of the House
of Delegates of the American Medical Association
should be held in Chicago late in May or some
time during the month of June.

After conference with official representatives
of the Office of Defense Transportation in Wash-
ington, I am quite convinced that permission to
hold a meeting at that time can not be had. I
was advised to file an application for permission
to hold a meeting of the House, to agree that
attendance should be held to a minimum and to
hold the meeting much later than originally con-
templated.

A letter is going forward to all members of
the House of Delegates whose names and ad-
dresses are available so that they may be informed
that the 1945 meeting of the House must be
deferred.

As soon as necessary arrangements can be
made, an announcement concerning the time and
place of the meeting of the House of Delegates
will appear in The Journal and all secretaries of
constituent state and territorial medical associa-
tions will be informed by telegram or by letter.

Olin West, Secy.

o

LOUISIANA TUBERCULOSIS ASSOCIATION

The annual meeting was held on Tuesday, April
17, at the Jung Hotel, New Orleans.

The morning program included papers by Drs.
John M. Whitney, I. L. Robbins and Maurice
Campagna. Following this session the business
meeting was held and Dr. Julius L. Wilson was
re-elected president of the organization. Dr.
Chester A. Stewart made an interesting report
on college health programs. At the luncheon
Dr. C. M. Sharp, of the U. S. P. H. S., discussed
the Federal program for tuberculosis conti’ol and
he in turn was followed by Dr. R. Alec Brown,
who spoke on its application in Louisiana. On
the afternoon program were Mr. W. S. Terry,
Director of the Department of Public Welfare;
Mr. Holland Hudson, Director of Rehabilitation of
the National Tuberculosis Association, and Mr.
Charlie Mitchell.

In the evening there was a round-table talk on
the problem of what to do about the Louisiana
men rejected by draft boards because of chest
conditions. This was participated in by Drs.
Sydney Jacobs, W. L. Treuting, R. Alec Brown,
John M. Whitney, J. E. Blum and Mr. Holland
Hudson.

o

NEWS ITEMS

Friday, April 6, 1945, Dr. Payton Rous of the
Rockefeller Institute for Medical Research, New
York, and on Friday, April 13, 1945, Dr. Arild
Hansen, Director of Pediatrics, University of
Texas, Galveston, were the guests of the Louisiana
State University School of Medicine in New Or-
leans. While here Dr. Rous gave an address on
“The Present State of the Cancer Problem” and
Dr. Hansen discussed “Some Phases of Lipid
Metabolism” and the “Evaluation of the Nutri-
tional State of the Child.”

Word has been received that Dr. Herbert R.
Unsworth, Clinical Assistant Professor of Neuro-
psychiatry at Louisiana State University School
of Medicine, has been appointed Attending Spe-
cialist in Neuropsychiatry at the U. S. Marine
Hospital in Carville, Louisiana.

The American College of Radiology in their
monthly news letter underlined the following sen-
timents: “You may expect the film situation to
get worse before it gets better.”

Scholarships for training in physical therapy
under the $1,267,600 program of The National
Foundation for Infantile Paralysis are available
immediately for classes commencing in June and
July, Basil O’Connor, president of the National
Foundation has announced.

The Board of Trustees of the United States
Pharmacopoeial Convention announces that they
have purchased a building probably to be used
only as temporary headquarters, located at 4738
Kingsessing Avenue, Philadelphia.

The Modern Hospital announces competition for
an essay on the subject, “A Plan for Improving
Hospital Treatment of Psychiatric Patients.”
These essays shall not exceed 5,000 words in
length and should be sent to the managing editor
of the Modern Hospital Publishing Company,
Chicago, before October 1. Details of the com-

I

Louisiana State Medical Society News

518

petition may be obtained at the office of The
Journal.

An acute shortage of teachers prepared to con-
duct classes for partially seeing children has
resulted in the closing of some classes and the
postponement of the establishment of others. At-
tention is therefore called to the fact that five
colleges and universities, in cooperation with the
National Society for the Prevention of Blindness,
are offering special courses for the preparation of
supervisors, teachers, nurses, social workers and
others concerned with the education of the par-
tially seeing child.

Dr. Robert Bennett Bean, anatomist and phys-
ical anthropologist, died on August 27, 1944, at
the age of seventy. From 1910 to 1916 he was
on the faculty of Tulane University School of
Medicine, first as associate professor and then
professor of gross anatomy. Subsequently he be-
came professor of gross anatomy at the Univer-
sity of Virginia.

o

THE INTERNATIONAL SOCIETY OF
SURGERY

The Board of Regents of the American College
of Surgeons has invited the International Society
of Surgery, through Dr. Rudolph Matas, secre-
tary, to make its official headquarters during the
wartime emergency in the College of Surgeons
Building in Chicago.

The International Society of Surgeons is the
oldest and leading international forum of surgery,
Louisiana membership is held by Dr. Matas, Dr.
Urban Maes, and Dr. Alton Ochsner. Dr. Matas
presided at the 1938 Congress held in Brussels.

CHARITY HOSPITAL

The regular monthly meeting of the Medical
Division of the Charity Hospital Visiting Staff
was held on Tuesday, April 17, in the auditorium
of the hospital. The following program was pre-
sented: Hansen’s Disease — Case Presentation, by
Dr. T. Ray, discussed by Dr. G. W. McCoy; Sur-
gical Conditions in Children; (a) Juvenile Hyper-
thyroidism, (b) Congenital Hemolytic Icterus, by
Drs. R. Tilbury and W. Sako; Case Presentation
by Dr. Platou and staff.

o —

DR. H. WINDSOR WADE
The Journal has received a clipping from the
New Orleans States of Wednesday, April 11, from
Dr. Rudolph Matas. Dr. Matas in his covering
letter states that “Dr. Windsor Wade gradu-
ated from Tulane in 1912, and had quite a repu-
tation in pathology in association with Duval. He
has made a great name for himself as a leprologist
since he has been given charge of the Colony at
Culion. He married Miss Dorothy Paul, a New
Orleans girl.”

The clipping is headed “In Today’s News Spot-
light” from International News Service. It reads
as follows:

“Liberation of the world’s largest leper colony
on Culion island in the Philippines by American
Eighth Army doughboys turned the limelight to-
day on Dr. H. Windsor Wade, world renowned
leprologist, head of the Culion medical staff for
the last 15 years.

“Dr. Wade, rescued from the island last Febru-
ary 10 by a United States Catalina plane, first
went to Culion as chief pathologist in 1922. His
experience in administering to the colony’s 5000
afflicted led him to world fame as an expert in
treatment of the disease.

“A native of Haddonfield, N. J., Dr. Wade
soon became closely identified with expansion of
anti-leprosy work in the Philippines, in 1927 was
co-author of a widely read book on the subject,
served as editor of the International Journal of
Leprosy and was honored with memberships and
honorary memberships in many international med-
ical societies, particularly those specializing in
leprosy.

“Under his direction, the Culion colony afford-
ed excellent medical treatment for the Philippine
archipelago’s lepers free of charge and even af-
fected many cures, once thought impossible. His
charges lived normal lives, administering their
own government, until the Japs came and through
starvation reduced the population from 5000 to
3000.”

o

HEALTH IN NEW ORLEANS

The Bureau of the Census, Department of
Commerce, reported that for the week ending
March 17 there occurred 135 deaths in the City
of New Orleans as contrasted with 113 the previ-
ous week. Of these deaths 78 were in the white
population, 57 in the negroes, and 10 of them
were in children under one year of age. For
the week which came to an end on March 24 the
total number of deaths had increased to 151, 91
of which were in the white and 60 colored, with
9 infants under a year of age. For the week
which closed March 31 there was a very sharp
reduction in the number of deaths, falling
to 108 and divided 70 white, 38 colored, and 9
infant deaths. The low number of deaths still
continued in the week which ended April 7 when
there were 116 deaths recorded, 71 of which were
in the white population, 45 in the colored, and 10
children under a year of age. The three year
average for the corresponding week shows it to
be 134 deaths.

— o —

MONTHLY STATISTICAL REPORT
MARCH, 1945

Estimated Population as of July 1, 1944

White 391,000

Colored 169,000

Louisiana Stale Medical Society News

519

Total 560,000

Total Deaths, All Causes 555

White 348

Colored 207

Resident Deaths, All Causes 437

White 282

Colored 155

DEATH RATES

(Per 1000 per annum for the month)

All

Non-residents

Deaths

excluded

White

.... 10.7

08.6

Colored

.... 14.7

11.0

Total

.... 11.9

09.4

rths Recorded..

1,095

White

732

Colored

363

Births

864

White

579

Colored

285

BIRTH RATES

(Per 1000 per annum for the month)
All Non-residents
Deaths excluded

White 22.5 17.8

Colored 24.0 20.2

Total 21.9 18.5

-o-

INFECTIOUS DISEASES IN LOUISIANA
For the week ending March 10 there were re-
ported to the Department of. Health the following
diseases in numbers greater than 10: Septic sore
throat 301, measles 110, pulmonary tuberculosis
38, chickenpox 22, scarlet fever 13, and malaria
and unclassified pneumonia 11 each. Dui'ing this
week there must have occurred an epidemic of
sore throat probably following ingestion of con-
taminated milk. Other unusual diseases include
one case of poliomyelitis and seven of meningo-
coccus meningitis. For the week which came to
an end March 17 diseases listed in the State Board
of .Health in numbers greater than 10 include
pulmonary tuberculosis 50, malaria 33, influenza
31, chickenpox and septic sore throat each 20,
mumps 16, unclassified pneumonia 13, measles 11.
For the week which terminated March 24 hook-
worm infestation led all other of the reportable
diseases, there being' 90 cases listed in this par-
ticular week. It was followed by 47 cases of in-
fluenza, 42 of measles, 40 of pulmonary tuber-
culosis, 37 of malaria, all of which came from
military sources, 19 of septic sore throat, 17 of
chickenpox, 13 each of mumps, scarlet fever, and
unclassified pneumonia. All the cases of malaiia,
it is to be noted, were contracted outside of Con-
tinental United States. The week ending March
31 contained the monthly venereal disease report.
There were listed 1,560 cases of gonorrhea, 1,318
of syphilis, 25' of chancroid, 18 of lymphopathia
venereum, and 7 of granuloma inguinale. The
other usual diseases included for some remark-

able reason 170 cases of unclassified pneumonia,
then followed 67 cases of pulmonary tuberculosis,
62 of pneumococcic pneumonia, 38 of measles, 30
of malaria, 57 of influenza, 21 of mumps, 15
each of scarlet fever and septic sore throat, and
14 of chickenpox. Eleven cases of chanci'oid, 740
of gonorrhea, and 80 of syphilis were reported
from military sources.

DR. RICHARD O. SIMMONS
(1868 - 1945)

One of the former presidents of the Louisiana
State Medical Society, Dr. Richard O. Simmons,
died at Alexandria on April 10, in the seventy-
seventh year of his life. Dr. Simmons graduated
from the Louisville Medical College in 1892 and
had practiced continuously in Alexandria since
that time. So highly valued was Dr. Simmons’
reputation as a doctor and his services to the
State Medical Society, that the 1942 meeting of
the organization was dedicated to this beloved
and respected physician.

Two paragraphs of the dedication tribute to
Dr. Simmons reprinted from the program of this
meeting give a fair estimate of the man and why
this meeting was dedicated to him. These para-
graphs read as follows:

“In honoring Dr. Simmons of Alexandria by
dedicating the 1942 meeting of the Louisiana
State Medical Society to him the organization is
paying tribute to a man who has for years been
actively participating in the State Medical Socie-
ty’s numerous functions; it is paying tribute to
a beloved physician who has been progressive in
his viewpoint and has put into action always the
latest proved innovations in medicine.

‘•Of the man it might be said that his patients
are devoted to him; his lovable, kindly disposi-
tion has made him a friend of every one; his
honesty of character has made him a champion
of everything that is of the best. Always willing
to fight for high medical ethics, he has done it
without being acrimonious and he accomplishes
what he sets out to do.”

— o—

DR. HILLIARD E. MILLER
(1893 - 1945)

Dr. Hilliard E. Miller died suddenly April 20 of
coronary occlusion. He was one of the best known
gynecologists in the South and was a member of
a large number of national medical organizations,
notably the National Board of Obstetrics and Gyne-
cology, as well as the American Gynecologic Club
of which he was president. Dr. Hilliard Miller
succeeded Dr. Jeff Miller as Professor of Gyne-
cology at Tulane University Medical School, a
position from which he resigned shortly before his
death. He was chief of the department of gyne-
cology at Touro Infirmary, senior gynecologist at

520

Book Revietvs

the Charity Hospital and senior consultant for the
Flint-Goodridge Hospital.

Dr. Miller was a man with a most attractive

personality. He had innumerable friends not only
in the profession but among the laity; all will
miss his cheerful smile and invariable courtesy.

0

BOOK REVIEWS

Introduction to Parasitology luith Special Refer-
ence to the Parasites of Man: By Asa C. Chand-
ler, M.S., Ph.D., 7th ed. New York and London,
John Wiley and Sons, Inc. 1944. pp. 716. Price,
$5.00.

Among the several texts on parasitology and
tropical medicine which have glutted the market
and confused the student during the past few
years it is heartening to have a new edition of
this standard text. The fact that the author has
been called on for the seventh time to present the
subject is evidence of its worth.

The “Introduction” is in no sense a mere elemen-
tary presentation, since it covers rather fully the
important etiological agents of human disease be-
longing to the animal kingdom. In addition to
an introductory chapter and one on parasites as a
whole there are eight chapters on the protozoa,
eight on the helminths, nine on arthropods, a list
of journals and monographs helpful in further
study of the subject and a subject index. There
is a good reference list at the end of each chapter.

The volume is intended primarily for courses in
parasitology in a university but is perhaps equally
suited for presentation of the subject to first-year
medical students. It is clearly written in an en-
gaging style, is authoritative and up-to-date. There
are numerous textual illustrations, most of which
are good and are clearly reproduced.

The reviewer cannot agree with Doctor Chand-
ler in grouping the spirochetes under the protozoa,
although he sympathizes with the author in the
conviction that there should be a presentation of
spirochetes in an introduction to parasitology.
Moreover, it should be pointed out that the head-
ing “Helminthology” is inconsistent when it is
used coordinately with “Protozoa” and “Arthro-
pods.” However, these criticisms are indeed trivial
when one considers the outstanding merit of the
book.

The volumd'is clearly printed on good paper and
is unusually free of typographical errors.

Ernest Carroll Faust, Ph.D.

The Biological Basis of Individuality: By Leo
Loeb, M. D., Springfield, 111., Charles C. Thomas,
1945. Pp. 711. Price, $10.50.

Dr. Loeb is Professor Emeritus of Pathology at
Washington University School of Medicine. For
almost fifty years he and his colleagues have been
concerned with the subject of this monograph —
the study of the organ and tissue differentials

which determine the structure, metabolism, motor
and psychical activities of individuals. He began
to assemble the data in 1930 and has taken fifteen
years to complete the task. The resulting volume
is, as one would expect, a carefully written, com-
pletely documented account of all phases of the
problem.

The book is divided into eight parts and in-
cludes discussions of the results of tissue trans-
plantation, differences between normal tissues and
tumors, tumor growth, heredity and transplanta-
tion of tumors, the bearing of immune processes
on the interpretation of organismal differentials
and the relation between species and organismal
differentials. In the last part, the author attempts
to explain the basis of psychical — social individual-
ity— the factors which make each individual unique
and with a specific personality.

Those readers who have followed Dr. Loeb’s
work will be grateful to him for bringing together
and interpreting the vast amount of interesting
material in this field. Those interested in genetics,
cancer and immunology, psychology and philoso-
phy, in fact, all serious students of biology will
find the book a source of much useful information
and stimulation.

H. S. Mayerson, Ph. D.

o

PUBLICATIONS RECEIVED

W. B. Saunders Company, Philadelphia and Lon-
don: Medical Gynecology, by James C. Janney, M.
D., F. A. C. S. A Manual of Tropical Medicine,
Prepared under the Auspices of the Division of
Medical Sciences of the National Research Coun-
cil. Peripheral Nerve Injuries, Principles of
Diagnosis, by Webb Haymaker, Capt., M. C., A.
U. S., and Barnes Woodhall, Maj., M. C., A. U. S.

The C. V. Mosby Company, St. Louis: Clinical
Case-Taking, by George R. Herrmann, M. D.,
Ph. D.

Grune & Stratton, New York: Trauma in Inter-
nal Diseases, by Rudolph A. Stern, M. D. Consti-
tution and Disease, by Julius Bauer, M. D.

The Year Book Publishers, Inc., Chicago: The
Examination of Reflexes, by Robert Wartenberg,
M. D.

Random House, New York: Yellow Magic, The
Story of Penicillin, by J. D. Ratcliffe.

D. Appleton-Century Company, New York and
London: Penicillin Therapy, by John A. Kolmer,
M. S., M. D., Dr. P. H., Sc. D., LL. D., L. H. D.,
F. A. C. P.

New Orleans Medical

and

Surgical Journal

Vol. 97 JUNE, 1945 No. 12

SPECIAL ASPECTS OF PRENATAL
CARE*

WALTER E. LEVY, M. D.f
New Orleans

I make no apology for the presentation
to a general audience of a paper on prenatal
care. I do not believe that any apology is
needed as long as there are annually in the
United States approximately 20,000 mater-
nal deaths, two-thirds of which are pre-
ventable, and 150,000 fetal deaths, half of
which are preventable, quite aside from the
enormous fetal loss which results from
abortion. We once had the unenviable
reputation of losing more mothers in child-
birth in this country than did any other
country in the registration areas of the
world. Fortunately that is no longer true.
But this nation, which has the highest
standard of living on earth, still has far to
go before its maternal and fetal death rate
comes anywhere near the irreducible mini-
mum.

It may be trite and axiomatic to say that
the prevention of maternal and fetal deaths
is almost 100 per cent dependent on the
kind of care the mother receives before her
labor begins, but it is worth saying again.
For a large proportion of the women in this
country still do not receive the proper care
during pregnancy, and many of them do
not receive any care at all. For this there
are a number of very obvious reasons. In

*Read before the Orleans Parish Medical So-
ciety, January 22, 1945.

fFrom the Depai’tment of Obstetrics and Gyne-
cology of the School of Medicine of Louisiana State
University, Department of Obstetrics of Touro In-
firmary.

the poorer and more sparsely settled parts
of the United States, such as the barren
Appalachian Mountains, the swamps of
Florida, and the “deep bayou country” of
Louisiana, few persons can afford to pay
for medical care, even if physicians, who in
all fairness have a right to expect some re-
turn for their long and expensive training,
can afford to settle in them. In Louisiana
there are only one or two large cities, only
a small number of large towns, a large
rural population, and a large negro popula-
tion. As a result, in 1942, only 53.8 per
cent of all births in this state occurred in
hospitals, against 69 per cent for the coun-
try as a whole, only 20 per cent were at-
tended by physicians outside of hospitals,
against 25 per cent for the country as a
whole, and 27 per cent were not attended
by physicians at all, against 7.7 per cent
for the country as a whole.

The maternal and fetal death rate in
Louisiana, it is true, has shown a marked
improvement in recent years, undoubtedly
as the result of the extension of public
health facilities, but it is still much higher
than for the whole country. How to change
this situation is not a part of this discus-
sion, though the training and supervision
of midwives would certainly improve it.
This is a perfectly feasible plan. Under it
the midwives of Philadelphia, for instance,
achieved a maternal mortality so much bet-
ter than the mortality of physicians in that
city that Dr. Brooke Anspach pessimistical-
ly wondered whether the modern obstetri-
can ought not to be regarded as a real men-
ace to the community.

Be that as it may, there are not enough
of him. Seventy-five per cent of all the

522

Levy — Prenatal Care

births in the United States are not attended
by obstetric specialists, and the fact that
for practical reasons they cannot be, par-
ticularly in the present emergency, makes
me somewhat out of patience with specialty
groups who are refusing to qualify practi-
tioners in small towns because they are do-
ing too much obstetrics. On the other hand,
there is no excuse for a man who under-
takes to do obstetrics, whether from patrio-
tic motives or otherwise, not doing it prop-
erly. And the basis of proper obstetrics is
proper prenatal care.

THE PLAN OF PRENATAL CARE

Prenatal care begins when a woman sus-
pects that she is pregnant and consults a
physician. Ideally, and quite impractically,
it should begin with a medical examination
before pregnancy occurs, which would
mean, in a small proportion of cases, that
conception would be advised against. It is
an encouraging fact, however, that most
women w7ho plan to be delivered by an ob-
stetrical!, and an increasing proportion of
women who plan to be delivered by a phy-
sician, now place themselves under medical
care at once. As a corollary, they thus
place upon their medical attendants the re-
sponsibility for their welfare, and that of
their unborn children, with the proviso, of
course, that they themselves follow the reg-
imen laid down for them.

The general plan of prenatal care in-
cludes :

1. A detailed history, a complete physi-
cal examination, a careful pelvic examina-
tion, and certain essential laboratory ex-
aminations, all of which are carried out at
the first visit, the first consideration of
which is to determine that the patient is
actually pregnant. If her menstrual his-
tory is irregular and if physical and pelvic
signs are not clearcut, the Aschheim-Zon-
dek test, or one of the less complicated tests
recently introduced, should be performed.

2. Instructions for a hygienic mode of
life, which include attention to bowel and
bladder function; a properly balanced diet;
provision for loose, sensible clothing and
shoes with low heels; eight hours’ rest at
night, preferably with a daily rest period

also; moderate exercise, preferably walk-
ing; restriction of smoking and drinking;
prohibition of sexual intercourse after six
months, of tub baths after seven and a half
months, and of douches at any time.

3. Reference of the patient to her den-
tist, and to consulting physician as neces-
sary.

At the first visit the proper relationship
between physician and patient should be
established. She should be told that gesta-
tion is essentially a physiologic function
and is likely to remain so in a woman un-
der supervision, who follows her physi-
cian’s instructions. But she should also be
told that it is a process which may become
dangerously pathologic in a very short
time. Therefore she should be warned to
report to the physician without delay any
apparent abnormality. As a result, the
physician is likely to be disturbed unneces-
sarily a good many times, though he is very
unlikely to have among his cases many
complications not detected in their in-
cipiency. Furthermore, a woman of self-
control and intelligence will not have many
complaints, while women of other tempera-
ments will have a good many, regardless
of instructions.

ASSOCIATED DISEASES

The detailed history taken at the first
visit should cover not only the symptoms
and signs of pregnancy but also all the
facts of the previous history. Questioning
should be specific as to previous pregnan-
cies, with special reference to abnormalities
of gestation and delivery, and to such previ-
ous diseases as tonsillitis, scarlet fever,
diphtheria, rheumatic fever, pyelitis and
other renal diseases, cardiac and pulmonary
disease, diabetes, and allergic states.

Neither in the history-taking nor the
physical examination should it be assumed
that the pregnant woman has nothing the
matter with her except her pregnancy. The
burden of proof should rest upon the
demonstration that this is the situation.
Furthermore, if another disease is found,
the concept should be that the pregnancy
complicates it, and not, as is usually stated,
that it complicates pregnancy. The discov-

Levy — Prenatal Care

523

ery of another disease should usually im-
ply prompt consultation with the appropri-
ate specialist, though in most cases it does
not imply therapeutic abortion. It might
be well to point out at this time that the
interruption of a pregnancy should never
be undertaken on the responsibility of a
single physician ; for his legal protection, if
for no other reason, a second opinion, prop-
erly recorded, should be secured.

Certain special diseases might be briefly
mentioned. The association of pregnancy
and diabetes, while possible, is unlikely,
which is fortunate, since the effect of dia-
betes on both mother and child is bad, and
insulin therapy under these circumstances
is less effective than usual. Furthermore,
toxemia is estimated to be about fifteen
times more frequent in diabetic than in
non-diabetic subjects. The continuation of
the pregnancy under skilled supervision is
probably the wisest course.

Unsuspected pulmonary tuberculosis is
by no means uncommon in pregnant wom-
en, and about its management there is no
unanimity of opinion, though there is gen-
eral agreement that conception should be
prevented in a woman with active tuber-
culosis, both because of the maternal risk
and because the child is usually born with
a constitutional inferiority. If it does oc-
cur, the continuation of the pregnancy un-
der proper medical supervision probably
does less harm than therapeutic abortion.
Latent or healed tuberculosis introduces
minimum risks in pregnancy with careful
management.

Most of the 4 to 8 per cent of maternal
deaths for which cardiac disease accounts
occur in badly managed cases and in cases
of decompensated disease. The opinion of
the internist should be followed as to
whether pregnancy should be terminated
in decompensated disease; in a large num-
ber of cases it should be. Compensated
cardiac disease and rheumatic heart dis-
ease offer only slightly increased risks un-
der proper management.

A patient with a previous history of
pyelitis is fairly 'certain to have one or more
exacerbations during pregnancy and de-

mands particularly careful watching. The
services of a specialist are frequently use-
ful. A woman with serious kidney disease,
especially if there is a history of nephritic
toxemia, should not be permitted to become
pregnant. If she does, therapeutic abor-
tion and sterilization are indicated, for her
risk increases with each succeeding preg-
nancy.

A blood serologic test should be carried
out on every pregnant woman when she is
first seen, for syphilis is no respecter of
persons. It is more common in the lower
social strata, of course, but it may occur at
any level. A positive serologic test should
be repeated, preferably by another technic,
and if a second positive reaction is report-
ed, treatment should be begun at once and
should be continued to term and beyond. A
patient with a history of syphilis, even if
her serologic reaction is negative, should
be treated intensively in every pregnancy.
Whether penicillin, whose effects in other
varieties of syphilis are apparently bril-
liant, will in the future alter the treatment
of syphilis in pregnancy it is too soon to
say.

It should also be emphasized that the
pregnant woman in the course of her ges-
tation is subject to all the surgical diseases
which may occur in a non-pregnant woman,
and which must often be treated as if they
were more important than the pregnancy.
Among these diseases are acute appendici-
tis, fibroid tumors of the uterus giving rise
to symptoms, dermoid cysts, which are in-
clined to grow rapidly during pregnancy,
hnd ovarian cysts with twisted pedicles. As
a general rule, these are surgical emer-
gencies, and from the maternal standpoint
they must be treated as such.

DIETARY REGULATION

I do not have a great deal of use for
elaborate dietary regulations in pregnancy.
The pregnant woman should be made to
understand the importance of a properly
balanced diet, with adequate supplies of
proteins, carbohydrates and minerals, and
an adequate but carefully restricted amount
of fat. We have now learned that there
is no relationship, as was once believed,

524

Levy — Prenatal Care

between a liberal protein content in the diet
and the development of toxemia, but rather
the reverse, a deficiency of protein often
being associated with toxemic states.

The patient should be told that she may
safely gain from 18 to 24 pounds in weight,
depending upon her height and build, but
that a larger gain is undesirable and may
be dangerous. Excessive gains can be pre-
vented by a moderate restriction of carbo-
hydrates, and by a rather careful restric-
tion of fats, which produce twice as many
calories as do other food elements. No
pregnant woman, however, need go hungry.
It is almost impossible for her to eat too
many vegetables and too much fruit, and
if she rounds out her diet with them she
will get all the vitamins she needs in their
least expensive and most readily assimilable
form. I see no point to the provision of
vitamins or of any other food element from
the druggist’s shelves when it can more
readily be secured from a properly balanced
diet.

The patient may perhaps need to be
warned against trying to keep herself thin
for fashion’s sake, or against trying to
keep her baby small. The first objective
may have dangerous consequences. The
second cannot be achieved. It is now be-
lieved that hereditary and other factors
have much more to do with the baby’s size
and weight than does the maternal diet, the
elements of which, however, must be ade-
quate for the child’s development, since the
fetus is a true parasite and will extract
whatever it may need from the maternal
organism.

EXERCISE, OCCUPATION AND TRAVEL

Violent exercise is contraindicated in
pregnancy, but walking is safe, healthful,
and fitted for any pregnant woman in
whom any exertion at all is not undesirable.
Women accustomed to driving their own
cars may continue to do so, at reasonable
speeds, until term.

The modern obstetrician is often faced
with a problem which did not trouble his
predecessors, the question of the working
mother. For economic and other reasons
the modern pregnant woman frequently

holds a job, at which she wishes to continue
to work as long as possible, and to which
she may hope to return after delivery.
Provided that the occupation is not one
which requires night work, work with toxic
substances, long hours of standing, or vio-
lent motions, I see no reason why it should
not be continued to within eight to ten
weeks of term.

Another problem which frequently con-
fronts the obstetrician, particularly at the
present time, is the safety of traveling.
Like most obstetricians, I formerly forbade
it, without, I grant, any reason other than
the tradition of my obstetric ancestors.
Diddle’s recent study on the effects, or
rather the lack of effects, of travel on the
incidence of abortion in a controlled series
of cases furnishes, so far as I know, the
first scientific data on the subject. They
are worth repeating. Of 446 women stud-
ied, 215 took no trips. The remainder
travelled from 170 miles to 6,000 miles
each, 127 miles in each case being over the
rough and bumpy causeway which leads
to Key West, where the study was made,
from the nearest railroad. The incidence
of abortion in the group which remained
sedentary was slightly higher than the inci-
dence in the group which traveled. For
many reasons, particularly at the present
time, it is wisest to advise the pregnant
woman, in the absence of a legitimate
cause for traveling, to remain at home, but
an increased risk of abortion is apparently
not among them.

VAGINAL DISCHARGES

The management of leukorrhea during
pregnancy calls for a word of comment. A
moderate vaginal discharge is physiologic.
A severe discharge demands investigation
and treatment. Whatever its nature, how-
ever. it should not be treated by the instilla-
tion of powder under pressure into the
vagina. Fatal air embolism has followed
this method of treatment within a few
minutes. If treatment of a discharge is
necessary, I insist upon making the topical
applications myself, and I positively forbid
douches.

Levy — Prenatal Care

525

TOXEMIC AND HEMORRHAGIC COMPLICATIONS

It is not necessary to point out to such
an audience as this that under proper pre-
natal care the death rate of toxemias of
pregnancy is reduced to a negligible pro-
portion, the antecedent chain of events in-
clude a reduction in their incidence because
they are detected in their incipiency. The
prompt reporting of untoward symptoms
and the performance of urinalyses and of
blood pressure determinations at frequent,
regular intervals permit the institution of
prophylactic measures when abnormalities
develop, followed by immediate hospitaliza-
tion and more active therapy if milder
measures are not effective.

The modern therapeutic concept is that
the control of toxemia should take pre-
cedence in the management of the preg-
nancy. In other words, the old idea that
immediate emptying of the uterus was the
basis of the treatment of toxemia has been
succeeded by the more rational concept that
after the toxemia is controlled, measures
to empty the uterus may be instituted as
the circumstances of the particular case de-
mand if the pregnancy has not already been
terminated by natural means. The old plan
was attended with a very high mortality.
The new method is attended with far
smaller mortality and sometimes, as in the
recent report of 152 cases by Arnell and
his associates from the New Orleans Char-
ity Hospital, with no fatalities at all.

The prompt report to the physician of
any bleeding at all, at any stage of gesta-
tion, will mean that some abortions can be
prevented and that many lives can be saved,
not only in placenta previa and premature
separation of the placenta but also in the
cases of ectopic pregnancy in which bleed-
ing is part of the syndrome. In this con-
nection it might be mentioned that a de-
termination of the patient’s blood type at
the first visit is a precaution which may
pay rich dividends later.

PELVIMETRY AND PELVICEPHALOGRAPHY

The almost categoric statement can be
made that there is never an excuse in a
case under an obstetrician’s care for any
period of time before labor for the develop-

ment of a crisis in which one must choose
between the life of mother and child be-
cause of a miscalculation as to size and
architecture of the maternal pelvis, or of
the fetal size. This is especially so, since
we have become increasingly “pelvic con-
scious” following the work of Caldwell and
Moloy. That does not mean, of course, that
promiscuous cesarean section is being ad-
vised, or that a properly supervised test of
labor is not permissible. It does mean,
however: (1) pelvimetry early in preg-
nancy; (2) its repetition at the end of eight
months, together with a repetition of the
pelvic examination, under sterile precau-
tions, in an endeavor to evaluate the size
of the presenting part in relation to the
pelvis. At the same time, the station of
presenting part is determined, and the ab-
dominal palpation is carried out to identify
the back and soft parts and to determine
the fetal poles, and fetal heart tones
auscultated.

Pelvimetry should always include an
accurate determination of the diameters of
the pelvic outlet, chiefly the transverse and
the posterior sagittal diameters. In certain
cases it will immediately make clear that
delivery by the vaginal route is impossible.
This is true of generally contracted pelvis,
certain types of contraction in various
diameters, and certain pelvic deformities.

More important, however, than the abso-
lute pelvic measurements is the relationship
of the passenger to the passage, that is the
size of the maternal pelvis in relation to
the size of the child. Until the recent in-
troduction of pelvicephalography there
might have been some excuse for miscalcu-
lations in this regard, but they no longer
exist. The use of external pelvimetry alone
means that only the false pelvis is meas-
ured, that there is no estimate of the size
of the child, and that the safety of delivery
by the vaginal route rests upon entirely in-
adequate information. The eight months’
pelvic examination just described provides
information as to the size and position of
the child, and makes clear whether or not
pelvicephalography should be carried out,
which it should be in the presence of any

526

Johnson — Arrhenoblastoma

pelvic contraction, any irregularity of pel-
vic architecture, and any abnormality in
the size of the child. The examination
should be made as near term as possible,
though preferably before labor begins,
since the complicated measurements re-
quired in the combined Johnson-Ball meth-
od, which most authorities believe to be
the most efficient thus far devised, are
more readily and more accurately made on
dry films. The recent report by Ane of
his own and Menville’s results in 362 cases
showed that the estimate of possible normal
vaginal delivery was 99 per cent correct
and the estimate of required operative de-
livery was 85.2 per cent correct.

It should be emphasized that 100 per cent
accuracy cannot be expected. This method,
in the first place, does not take the place
of the obstetrician’s clinical judgment. In
the second place, when a test of labor is
permitted in abnormal cases, and even
when the pelvis is normal in all respects,
it makes no allowance for the molding of
the fetal head or for the effectiveness of
the maternal pains.

SUMMARY AND CONCLUSIONS

The plan of prenatal care which has been
outlined is based upon simple common
sense. There is no reason to make it com-
plicated, even in the honest belief that
women are more likely to obey complicated
than simple instructions.

It is based upon continuous observation
of the patient by the physician. Office
visits are made every two weeks during
the first seven months of pregnancy, every
week thereafter. Telephone reports ate
made whenever necessary, with personal
observation according to the nature of the
reports. In other words, the channel of
communication between the patient and
physician is never closed. This plan takes
time and trouble, but it is abundantly justi-
fied by the results. The proper way to
reduce maternal and fetal mortality is to
provide proper prenatal care.

The responsibility of the medical profes-
sion in the provision of prenatal care is two-
fold. First, we must educate women to
seek it early in their pregnancy. We can

no longer justify deaths due to lack of care
on the ground that it was not sought. Sec-
ond, we must see to it that the care we
provide is of the sort which will not only
save two lives but which will prevent those
lives from ever being put into jeopardy.
Unfortunately, that is not yet true. As late
as 1937 Comyns Berkeley was making a
statement that is still, regrettably, of very
general application : “It is obvious from the
mortality reports that . . . antenatal care
falls far short of what might reasonably be
expected both in quality and amount.” It
behooves the whole profession to alter that
sorry situation.

DISCUSSION

Dr. E. L. King (New Orleans) : I have nothing
to dispute. All I can say is that Dr. Levy has
covered the ground adequately and to say that I
am sorry more of the members of the Society are
not here to profit by it.

I wish to emphasize the fact that, as brought
out, proper prenatal care is essential and will re-
duce maternal mortality. It is a nuisance some-
times, you might say, to have patients around all
day long taking blood pressures and examining
normal specimens of urine. You have to do that
though to catch the abnormal cases; not wait until
there are convulsions.

Some system should be devised to get prenatal
care over to all the population better than it is
at present. There has been a great deal done in
this regard. More would have been done if the
war had not come along and curtailed this, espe-
cially in rural districts. There has been a great
advance in Louisiana in the past fourteen years
and when the fighting is over and we get back to
normal there will be still greater advance.

Dr. Walter E. Levy (in closing) : I have noth-
ing to add.

0

OVARIAN ARRHENOBLASTOMATA

C. GORDON JOHNSON, M. D.f
New Orleans

Of the few ovarian tumors that exert en-
docrine influence upon the individual, the
arrhenoblastoma by far presents the most
colorful picture. It is also the rarest of
the ovarian tumors, but in most cases the
clinical findings are quite definite, and the
diagnosis can usually be made preopera-

fFrom the Department of Gynecology, Tulane
University of Louisiana School of Medicine and
Charity Hospital of Louisiana.

Johnson — Arrhenoblastoma

527

tively. To date there have been approxi-
mately 60 such cases reported in medical
literature. Long- and Ziskind3 reporting- on
98 solid ovarian tumors from the New Or-
leans Charity Hospital in a ten year period
1932-1941 found one case of an arrheno-
blastoma. My case was diagnosed during
1943, and it is indeed unusual, considering
the rareness of the condition, for two such
tumors to be found in the same institution
within a period of 12 years. Perhaps as
these authors suggest, further study of
solid ovarian tumors that in the past have
simply been diagnosed as fibromas, may re-
veal the presence of an arrhenoblastoma or
some other member of the special ovarian
tumor group, such as granulosa cell tumor,
theca cell tumor, Brenner tumor or disger-
minoma.

The four conditions that must always be
differentiated are; cortical tumors of the
adrenal, pituitary basophilic adenomas.
adrenal cell rests of the ovary and luteomas
of the ovary. In adrenal tumors the
breasts remain of normal size, and there is
marked hirsutism. A tumor sometimes
may be felt in the kidney region, and there
may be other adrenal symptoms. In baso-
philic pituitary adenomas the patients are
usually obese and present other symptoms
such as severe headaches, referable to a
pituitary lesion. Hirsutism is not a
marked feature. Adrenal cell rests may
sometimes be found in an ovary and pro-
duce a tumor that exerts a masculinizing
influence upon an individual similar to
those with an arrhenoblastoma. Such a
tumor is usually a highly malignant one and
the differentiation can only be made by mi-
croscopic examination. The ovarian lu-
teoma is considered by Schiller and Novak
to be really a tumor of adrenal tissue in
most instances; therefore a differentiation
clinically would be a difficult, if not im-
possible problem.

The theories of origin according to Krock
and Wolferman2 are as follows:

1. Hermaphroditic basis. Pick first
suggested this, but it soon became apparent,
however, that such was not tenable, because
as a rule the patient has developed ana-

tomically and physiologically as a normal
female, until the tumor exerts its influence
by changes in secondary sex characteris-
tics. Bisexuality must be present from
birth to be a true hermaphrodite.

2. Gonadal protective effect. Halbon
stated that the zygote is primarily male,
female, or hermophrodite, and that the go-
nads exert a protective effect, and not a
formative influence upon the development
of secondary sex characteristics. In other
words, all primary and secondary sex
characteristics are established from the
beginning. For the full development of
secondary sex characteristics a protective
effect from the gonads themselves is neces-
sary. The tendency of certain tumors to
change these secondary sex characteristics
may be due to the fact that the tumor itself
exerts a hyperprotective effect upon late
male elements, and when the tumor is re-
moved reversion occurs because of with-
drawal of the protective male element and
resumption of normal ovarian function.

3. Origin from latent male elements.
Robert Meyer suggested that the cell mass
destined to become the sex gland is at first
indistinguishable as male or female, and
that later cords of cells appear beneath the
germinal epithelium, and extend down to-
ward what later becomes the hilum. That
in the male they become permanent as semi-
niferous tubules, in the female they
atrophy; the true ovarian structure is then
built up around them and they become fos-
silized in the “rete ovarii” as Novak5 ex-
pressed it. Mayer believes that these cells
retain male potentialities. The unsolved
question here is, however, what causes
these abnormal cells to become so active
that they overcome normally developed
ovarian tissue.

4. Teratomatous origin. Popoff in 1930
suggested that these tumors may be one-
sided teratomata, citing Ewing’s conclusion
as to the origin of embryonal carcinoma of
the testicle and L’Esperance’s concerning
embryonal carcinoma of the ovary. Pick
has stated that a single element in a tera-
toma may predominate and suppress all
others. Krock called attention to this in

528

Johnson — Arrhenoblastoma

1933 when he found cartilage in his case.
Krock and Wolferman in 1941 reported on
70 collected cases in which evidence is
given to support the conclusion that from a
purely pathologic standpoint, arrhenoblas-
toma may represent one-sided teratomata.
In 24 instances there were found sugges-
tions of endermal tissue elements on rou-
tine microscopic examinations, and sug-
gested that serial sections might even show
more. The case which I shall report offers
additional circumstantial evidence in favor
of this theory, as a dermoid cyst was found
in the ovary which did not contain the
arrhenoblastoma.

Pathologically there are three types of tu-
mors. First there is the highly differenti-
ated “ovarii testiculari” described by Pick,
in which the seminiferous tubules may be
quite perfect and rete structures may be
present. Secondly there is the poorly dif-
ferentiated type where the growth consists
of sarcoma-like cords or tubules of solid
masses of cells, quite similar at times to
granulosa cell tumors. Lastly, there is the
intermediate group described by Meyer
with atypical tubules and cords presenting
great variation in structure, and often dif-
ficult to identify, analogous to similar
granulosa cell tumors. Recognition is
often done through the discovery of a few
tortuous cords or tubules of cells.

Most authorities report very little mas-
culinization in tumors that are of the well
differentiated type, but this is not always
true. The case which I am r eporting showed
marked masculinization, yet the micro-
scopic picture is that of a well differenti-
ated type. Konte and Ragins1 report a case
of the intermediate type in a patient aged
47, who six weeks after removal of both
ovaries and uterus, showed return of the
clitoris to normal size and complete absence
of hair on the chest. Boltuch'* reported a
case of the undifferentiated type in a wo-
man aged 28, who twelve days after re-
moval of the involved ovary, showed a be-
ginning resumption of normal voice, and
complete return of menstruation on the
twenty-sixth postoperative day, with nor-

mal breasts, and disappearance of abnor-
mally placed hair.

CASE REPORT

The patient, a young colored female, aged 24,
was admitted to the hospital on February 20, 1943,
with a chief complaint of cessation of menses and
pain, and mass in the lower right quadrant.

P. /.: The present illness dates back to nine

years ago when at the age of 15 she suddenly

Fig. 1. Facial hirsutism before removal of the
ovarian tumor. February, 1943.

ceased menstruating. Menarche was at 11 years,
with a regular cycle of thirty days, with a period
of three days. The cessation of menses was sud-
den and did not taper off. She went to see a
physician who gave her some medicine and six
months later she menstruated, but has not done
so since. The patient noticed that her voice be-
came harsher and deeper, the breasts became
smaller and there was an excessive growth of
hair over the body. It was necessary for her to
shave daily. She states that she did not lose any
sexual urge, and that she liked to go out and pet
with the boys.

The summer of 1942, she experienced a pain in
the right lower quadrant with fever and slight
nausea. She consulted a doctor in the country
who sent her to Charity Hospital.

P. H.: Patient was married at the age of

twenty, with no pregnancies. The patient has for

Johnson — Arrhenoblastoma

529

the last ten years drunk large quantities of water
and has passed more than a gallon of urine (by
measure) several times at night.

Recently she has had some blurring of her
vision, and frontal and parietal headaches. She
suffers from hot flushes.

P. E.\ P. B. 132/100, temperature 98.8°, pulse
80, respirations 18. There is a thick growth of
hair on the upper lip, chin and throat. The thy-
roid is palpable.

Fig. 2. Showing patient just prior to operation.

A large mass is felt in the lower abdomen
measuring 10x7 cm. The mass is tender. The
hair on the abdomen is masculine in distribution.

The clitoris is enlarged to the size of the distal
phalanx of the little finger. The cervix is in-
fantile in type. The uterus is small and retro-
verted. The left ovary is prolapsed and en-
larged and a large mass is felt in the right ad-
nexal region.

Laboratory : February 22, 1943, red blood cells
4,150,000, hemoglobin 75 per cent, white blood
cells 6,000, polys 60 per cent, lymphocytes 19
per cent, monocytes, 19, eosinophiles 2 per cent.
Urine negative on February 23 and March 4.
B. M. R. on February 23 was +26, and February
26, +11 per cent. X-ray of the skull on Febru-
ary 23, lateral view, showed no evidence of ero-
sion of the sella, abnormal convolutional mark-
ings or calcifications.

A preoperative diagnosis of arrhenoblastoma of
the right ovary was made and on February 27

the patient underwent a laporatomy. A supra-
cervical hysterectomy, bilateral salpingo-oophorec-
tomy and appendectomy was done; the left ovary
being removed because it contained a tumor and
the supra-cervical portion of the uterus being re-
moved because both ovaries had to be. Her post-
operative course was uneventful and she was dis-
charged on the twelfth postoperative day. Stil-
bestrol in dosage of 1 mg. three times daily was
started on the fourth postoperative day and she
was advised to continue this after leaving the
hospital. She did not, however, do this.

Pathologic Report, Gross Description-. The
specimen consists of a uterus, both tubes and
ovaries, and a small portion of the cervix. The
uterus measures 7.5 x 5 x 3 cm. The myometrium
is 1 cm. in thickness. The endometrial cavity is
normal in size and the endometrium 1 mm. in
thickness. On the left the fallopian tube is ad-

Fig. 3. Dermoid of left ovary and arrhenoblas-
toma of the right ovary.

herent to an ovarian mass measuring 4.5 cm. in
diameter. Its external surface is smooth and
grayish-white in color. Cut section of this tumor
mass reveals a cavity 3 cm. in diameter which is
filled with soft yellow grumous material, and also
some black hairs.

The right ovary is composed of a mass 13 cm.
in diameter. Its capsule is white and smooth,
but scattered here and there under the capsule
can be seen hemorrhagic areas of varying sizes.
The surfaces exposed by cutting show somewhat
of a soft heterogenous surface composed of soft,
yellowish, areas varying in size from 1 to 4 cm.
Scattered throughout are also nodular hemorr-
hagic areas of varying sizes. Both these nodular
areas are separated by trabeculations of fibrous
tissue. A few small cysts up to 1 cm. in diameter
are scattered through the tumor. The right fal-
lopian tube is firmly adherent to the capsule and
stretched.

Microscopic Description: Section through both

the tubes revealed a thickening of the wall with

530

Johnson — Arrhenoblastoma

some degree of fibrosis. A number of plasma
cells can be seen in the wall. Small areas of
glandular formation, composed of mucosal tubal
glands can also be seen buried into the muscula-
ture. The membrane is flattened and fibrosis
can be seen in the stalks. The myometrium is
normal. The endometrium is atrophic and shows
early progestational changes.

The left ovary reveals numerous corpora amy-
lacia. Dense areas of hyalinization are present, in
which is imbedded, here and there, calcareous ma-
terial. In one area, groups of xanthomatous
cells can be seen. In one area can be seen a cyst
wall lined by a flattened epithelium.

The right ovarian tumor consists in the main of
tubular like structures with imperfect lumens.
The cells composing these structures have large
basally situated nuclei, the cytoplasm of which
more or less streams into imperfect lumen. The
nuclei are vesicular and the chromatin is gathered
in clumps. The cytoplasm is eosinophilic and
granular. Here and there gathered in clumps
throughout, are small areas of interstitial cells.
The interstitial and supporting tissue is made up
of strands of well formed connective tissue. In
certain areas there is necrosis and hemorrhage.
Occasionally, one sees, in small areas, neoplastic
cells which have lost their polarity and are scat-
tered as single or small nests of cells in the inter-
stices of the connective tissue.

The diagnosis was bilateral salpingitis, left
ovarian dermoid cyst, atrophic progestational en-
dometrium and arrhenoblastoma of the right
ovary of adult type.

FOLLOW UP OF CASE

Before operation on February 27, 1943.

1. Abrupt cessation of menses at 15.

2. Onset of masculinizing traits at this
time (deepening of voice, appear-
ance of hair, a beard, masculine phy-
sique, atrophy of breast. Progressive
increase in sex desire, hypertrophy
of clitoris (all progressive from 15
to time of admission at 24).

3. Had pain in lower abdomen, head-
aches.

4. Right abdominal mass found.

5. Marked hypertrophy of muscles of
shoulders and upper extremities.

She was readmitted to the hospital on
November 20, 1943. Since leaving the hos-
pital she had noticed the following:

1. Hot flushes — 3-6 day.

2. Night sweats.

3. Decrease in number and intensity of
headache.

4. Marked increase in size of breasts.

5. Loss of much hair on abdomen, back,
arms, and legs. Still has beard,
shaves twice a week, not so thick,
and does not grow as fast.

6. Decreased libido.

7. No change in voice.

8. Gain of 22 lbs.

9. Some decrease of clitoris enlarge-
ment.

10. Muscles of upper extremity almost
same.

11. Chest plate negative for metastic le-
sion.

She was again put on stilbestrol in dos-
ages of 1 mg. three times daily and advised
to continue this drug until seen again. Her
general health was excellent and she
seemed quite satisfied with the results ob-
tained following the removal of the pelvic
organs.

SUMMARY AND CONCLUSIONS

A proved case of an arrhenoblastoma of
the ovary in a 24 year old colored female
has been reported with a follow up nine
months after removal of the tumor. Mi-
croscopic examination showed it to be of
the adult or well differentiated type. Fol-
lowing its removal the patient became more
feminine but still retains some of the male
characteristics that had developed in her at
age 16. She retained her deepened voice,
the clitoris remained somewhat larger than
normal and the muscles of the upper ex-
tremity showed little change. She also re-
ported that she still grew a beard that re-
quired shaving, but much less than before
operation. It is hoped that in time most of
these male characteristics will continue to
diminish.

The finding of an early progestational
endometrium was indeed interesting and
rather difficult to explain. The presence
of a dermoid cyst in the opposite ovary of-
fers additional circumstantial evidence in
support of the theory of teratomatous
origin of the ovarian arrhenoblastoma.

NOTE : I wish to acknowledge and also thank

Dr. Bjarne Pearson of the Department of Path-
ology, Tulane University, for his excellent de-
scription of the tumor.

Saunders — Common Medical Emergencies

531

REFERENCES

1. Konte, Aaron, and Ragins, Alex. : Arrhenoblastoma
of the ovary, Am. J. Obst. & Gynec., 42 :1061, 1941.

2. Krock, Fred, and Wolferman, S. G. : Arrhenoblastoma
of the ovary, Ann. Surg., 114 :78, 1941.

3. Long. C. H., and Ziskind, J. : Special ovarian tu-
mors, with report of series of cases, J. Tennessee M. A.,
36 :5, 1943.

4. Curtis, Arthur : Textbook of Gynecology, Fourth Edi-
tion. (Philadelphia, W. B. Saunders Co., 1942.

5. Novak, E. : Gynecological and Obstetrical Pathology,
W. B. Saunders Co.. 1940, p. 357.

6. Boltuch, S. M. : Masculinizing tumor of ovary

(arrhenoblastoma), Am. ,T. Obst. & Gynec,, 39:857, 1940.

O

DIAGNOSIS AND TREATMENT OF
SOME COMMON MEDICAL
EMERGENCIES

MARIDEL SAUNDERS, M. D.

New Orleans

INTRODUCTION

The purpose of this paper is to gather
together the diagnostic signs and symptoms
and accepted methods of therapy of the
common medical emergencies.

Because of the magnitude of the subject,
discussion will be limited to those situations
in which the patient’s life is in immediate
danger or in which failure to begin treat-
ment at once will result in irretrievable
damage to and inevitable death of the pa-
tient. No attempt will be made to evaluate
new and unproved methods. Authorities on
the subject will be quoted, wherever pos-
sible, and clinically tested methods outlined.

SHOCK

Shock arises from a great variety of
causes,1 but the essential pathologic physi-
ology is the same in all cases — a dispropor-
tion between the capacity of the vascular
system and the amount of fluid within the
vessels. If this disproportion is not reme-
died at once, the patient will surely die.

The patient in shock is pale, his expres-
sion anxious, his skin cold, clammy and
perhaps cyanotic. His pulse and respira-
tion are rapid. His blood pressure and
body temperature are low. This clinical
picture and the presence of hemoconcentra-
tion are sufficient evidence for diagnosis.
Hemoconcentration is most readily and ac-
curately gauged by hematocrit readings or
by the falling drop method of determining
specific gravity of the blood; The latter,

since it requires only a drop of blood, is
useful when collapsed veins make venepunc-
ture difficult.2

Treatment : ( 1 ) . Morphine sulfate, % to
1/2 grain, must be given at once, and re-
peated in an hour, to control pain and rest-
lessness.3

(2) . Plasma should be given by intra-
venous infusion at once. If it is not im-
mediately available, an infusion of physio-
logic saline, 10 c. c. per pound of body
weight, is advisable, while waiting for plas-
ma to be prepared.4 The amount of plas-
ma required to restore blood volume to nor-
mal is 100 c. c. for each point that the
hematocrit exceeds 45 per cent.5 However,
there is danger of precipitating cardiac em-
barrassment and pulmonary edema if an at-
tempt is made to replace, by one rapid in-
fusion, the entire amount of lost fluid. It
is wise to divide the doses of plasma, giv-
ing one-quarter of the total amount during
the first hour, one-quarter during the next
two hours, one-quarter during the next
three hours, one-quarter during the next
four hours.

(3) . Oxygen, by nasal catheter, face
mask, or tent, should be given to all pa-
tients in shock and is especially indicated
in respiratory conditions.

(4) . Adrenal cortical extract, 25 c. c. in-
tramuscularly,3 is a valuable adjunct to
blood plasma. This dose may be repeated
at the first sign of returning shock.2

(5) . Heat should be used very cautious-
ly. If the patient is swathed in blankets
and hot water bottles, the compensatory
constriction of his skin vessels will be re-
placed by vasodilatation. This will serve
only to deplete further the blood supply to
his heart, lungs and brain, and to deepen
his state of shock.6 A safe and effective
way of gradually restoring body tempera-
ture to normal is to place the patient under
a heat tent arranged with several small
electric light bulbs which may be turned on
one by one.3

HEMORRHAGE

The types of hemorrhage most likely to
be encountered on medicine wards are

532

Saunders — Common Medical Emergencies

hemoptysis, epistaxis, gastrointestinal hem-
orrhage, and cerebrovascular accidents.

A. Hemoptysis: Hemoptysis may result
from pneumonia, tuberculosis, whooping
cough, lung abscess or gangrene, bronchi-
ectasis, spirochetal bronchitis, pulmonary
neoplasms, blood dyscrasis, or cardiovascu-
lar disease2 such as mitral stenosis, pulmo-
nary edema, or rupture of aortic aneu-
rysm.7 Diagnosis is made by observation,
when the patient expectorates large quanti-
ties of blood. Rales, dulness on percussion
and the patient’s complaint of pain in a
particular area of the lung will usually
serve to localize the bleeding site.

Treatment: Treatment depends on the
extent of hemorrhage. If bleeding has
been profuse enough to cause shock, anti-
shock measures as outlined above must be
instituted, with the substitution of whole
blood for plasma.2 In less severe cases,
treatment consists of measures to insure
rest of the lungs, to promote clotting, and
to collapse the involved lung.7

(a) Rest: (1). Absolute bed rest, with
the patient’s head moderately elevated, is
imperative.

(2). Sedation in the form of barbitu-
rates — sodium phenobarbital, 3 grains,
should be given at once, and repeated as
needed for restlessness.

(3.) For severe cough codeine sulfate,
1/2 grain, is preferable to morphine, which
is too powerful a depressant.

(4). A three to five pound weight placed
on the chest decreases respiratory move-
ments and keeps the patient quiet in bed.

(b) Hemostasis: (1). One c. c. of surgi-
cal pituitrin, 10 c. c. of 10 per cent calcium
gluconate, 10 to 20 units of parathyroid ex-
tract, or 10 to 15 c. c. of one per cent aque-
ous solution of Congo Red, given intraven-
ously, may be tried for their hemostatic
effect.

(2). If the hemoptysis is large and re-
peated, ligatures around the extremities to
lessen venous return to the heart, and
thence to the pulmonary circulation, may
be of value.

(c) Collapse Therapy: Artificial pneu-
mothorax is especially indicated in severe

tuberculous hemoptysis and is useful as an
emergency measure in bleeding bronchiec-
tasis or chronically bleeding lung abscess.

R. Epistaxis : Epistaxis resulting from
hypertension is frequently life saving to
the patient, but occasionally may be so se-
vere and so prolonged as actually to en-
danger life. In these cases, anterior and
posterior packs must be inserted into the
nasal passages to control hemorrhage. If
severe arterial bleeding recurs after remov-
al of the packs, the patient should be re-
ferred to an ear, nose and throat specialist
for ligation of the bleeding vessels.8

C. Gastrointestinal Hemorrhage : Gastro-
intestinal hemorrhage may be caused by
peptic ulcer, esophageal varices, malig-
nancy, blood dyscrasias, acute gastritis and
acute febrile diseases such as typhoid fever,
malaria, yellow fever and malignant scarlet
fever.9

Acute gastrointestinal hemorrhage is ac-
companied by hematemesis and melena if
the lesion is in the stomach, by melena
and/or the passage of fresh blood if the in-
testines are involved. Depending on the ex-
tent of exsanguination, systemic signs of
hemorrhage — weakness, sweating, thirst,
pallor, dizziness, and, in extreme cases,
shock — may or may not be present.

Treatment : ( 1 ) . Emergency treatment is
symptomatic. Absolute bed rest in the
Trendelenberg position, a 24-hour period of
complete starvation, warmth, sedation and
typing and cross matching of the patient’s
blood are the essential measures in all cases
of gastrointestinal hemorrhage.10

(2) . Sodium phenobarbital, 11/2 to 2
grains,9 is often a more effective sedative
than morphine, which tends to produce
nausea, but the latter drug may be required
if the patient is suffering from pain as well
as restlessness and apprehension. The dose
is 1/8 to 1/4 grain. Sedation should be re-
peated often enough to keep the patient
quiet and calm.

(3) . Immediate blood transfusion is not
indicated except in cases where signs of se-
vere blood loss or shock obtain. If the red
cell count is below 2,500,000, or the hemo-
globin below 50 per cent, or if the blood

Saunders — Common Medical Emergencies

533

pressure is falling and the pulse rate ris-
ing rapidly, 300 to 500 c. c. of whole blood
should be transfused in one-half to one
hour. If no blood is immediately available,
slow infusion of 500 c. c. of saline solution,
with or without glucose, is advisable as a
temporary measure. If the patient shows
no signs of severe blood loss, watchful wait-
ing is the best policy. The blood pressure
and pulse rate should be checked every hour
during the first day. If the pulse reaches
130 a minute, or the systolic pressure drops
below 90 mm. of mercury, transfusion is
indicated.10 Further treatment depends on
the cause of the hemorrhage and is beyond
the scope of this paper.

D. Cerebrovascular Accidents : Cerebro-
vascular accidents include cerebral hemor-
rhage and thrombosis, embolism and sub-
arachnoid hemorrhage. The problem here
is one .of diagnosis since the patient is in
coma which must be differentiated from
coma from other causes. A full discussion
of all the differential points in these vari-
ous conditions would constitute a paper in
itself. However, there are a few charac-
teristic signs and symptoms found in each
condition which will usually make the diag-
nosis. It is always necessary to perform a
complete physical examination and labora-
tory work-up, and, if possible, secure a his-
tory from the patient’s relatives or whom-
ever brought him in for treatment.

In discussing the differential diagnosis
the problem will be simplified somewhat, I
believe, by dividing the various causes of
coma into functional or extracranial causes
and organic or intracranial causes. The
former group includes diabetic coma, hypo-
glycemic shock, uremic coma, drug poison-
ing, alcoholic coma, hysteria, post-epileptic
coma, heat stroke, heat exhaustion. In this
group generalized convulsions and respira-
tory changes are important physical find-
ings and blood chemistry plays a significant
role in diagnosis. The organic group in-
cludes meningitis and encephalitis, brain
tumor and abscess, skull injury, brain
trauma, and cerebrovascular accidents. In
this group, localizing neurological signs,
meningeal irritation and changes in the

cerebrospinal fluid are prominent. Al-
though the finding of either one of these
syndromes does not invariably indicate the
t;ype of lesion present, it does in a general
way direct the attention in one or the other
direction, and suggests the immediate need
of blood chemistry determinations as
against lumbar puncture, for example.

FUNCTIONAL OR EXTRACRANIAL COMA

The diagnosis and treatment of diabetic
coma, hypoglycemic shock and uremic coma
will be taken up later under the appropriate
headings.

(1) . Acute Alcoholic Coma : A history
of alcoholism, or of a recent debauch, and
the presence of an alcoholic odor on the
breath, hyperemia of the face, throat and
conjunctivae, and — in more severe cases —
depressed respiration, cyanosis, dehydra-
tion, enlarged heart, pulmonary rales, and
low blood pressure will give a tentative
diagnosis.11 This may be confirmed by
finding a blood alcohol level of 300 mg. per
cent or more.12 A careful check for asso-
ciated head injury should always be made
in these cases.

Treatment: Emergency treatment of

acute alcoholism consists in gastric lavage,
direct stimulation of the respiratory cen-
ter by caffeine, 0.3 gram, hot coffee, strych-
nine 0.002 gram, or atropine 0.001 gram,
reflex stimulation by means of smelling
salts or ammonia water, or the administra-
tion of aromatic spirits of ammonia.13 If
the patient appears dehydrated, fluids can
be administered through the stomach tube.
If respiration is rapidly failing, artificial
respiration may have to be instituted. In-
travenous infusion of 10 per cent glucose
in saline should be started at once.14

(2) . Post-epileptic Coma: The history
of a convulsion preceding the comatose
state and the discovery of scars or fresh
lacerations on the patient’s tongue, chin or
occiput, especially if other physical findings
are negative, will make this diagnosis.11 In
the absence of any of these signs, the fact
that the patient may be aroused from coma
in fifteen or twenty minutes is fairly good
evidence of the epileptic nature of the at-
tack.

534

Saunders — Common Medical Emergencies

Treatment : No treatment is required for
post-epileptic coma unless the patient is in
status epilepticus and is passing from coma
into convulsive attack without ever regain-
ing consciousness. Here death from heart
failure or exhaustion is to be feared, unless
the attacks can be stopped. Intravenous
injection of 5 to 7^4 grains of sodium phe-
nobarbital is usually effective. If not, the
inhalation of one of the volatile anesthetics
may bring a cessation of the convulsions.
Another method is the rectal administra-
tion of 4 drams of paraldehyde in olive oil,
after a cleansing enema. Intravenous in-
fusion of 250 to 500 c. c. of 5 per cent glu-
cose solution or normal saline should be
given to combat the exhaustion following
repeated seizures.13

(3) . Hysteria : Normal reflexes, respir-
ation and pulse, bizarre and irregular move-
ments of the arms and legs, tightly closed
eyes or rapid jerky movements of the eye-
balls when the lids are forced open, are
present, and dilated pupils, cyanosis, in-
voluntary micturition, injury or laceration
of the tongue are absent in hysterical coma,
whereas the reverse is true of coma due to
organic causes.16 Hysteria is not a medical
emergency and requires no immediate
treatment.

(4) . Drug Poisoning : Barbiturates,

carbon monoxide, the opiates and corrosives
cause the majority of cases of drug coma.12
Coma due to chloral hydrate, paraldehyde,
chloroform, cyanide, atropine or scopola-
mine is less common.13 Since all of these
drugs are respiratory and central nervous
system depressants, the history is of con-
siderable importance in making a differ-
ential diagnosis. However, there are a few
characteristic physical findings to be
watched for. Cherry red skin and mucous
membranes and the odor of illuminating
gas mean carbon monoxide poison. Pin-
point pupils and extremely slow respiration
are characteristic morphine effects. Cor-
rosive agents may be detected by the find-
ing of eschars in the patient’s mouth. Pa-
raldehyde causes a disagreeable odor of
fusel oil on the breath. Cyanide smells
like almonds, and chloroform, of course,

has its own peculiar odor. Atropine and
scopolamine cause flushing of the face and
blush area, dryness of the mouth, dilation
of the pupils and rapid heart action. Chloral
hydrate and the barbiturates cause no char-
acteristic signs and are impossible to diag-
nose without a history.11

Treatment: Specific treatment of all the
various types of poisoning is too large a
subject for inclusion in this already overly
ambitious paper, but a brief word about
general methods is indicated. “Gaseous
poison should be treated with fresh air,
artificial respiration and oxygen and car-
bon dioxide inhalation.”11 When cyanide is
the toxic agent, the patient should be made
to inhale amyl nitrite; intravenous injec-
tion of 0.3 gram of sodium nitrite in 10 c. c.
of water, followed immediately by 50 c. c.
of a 50 per cent solution of sodium thio-
sulfate through the same needle, must be
given at once.17 Ingested poison should be
promptly removed by gastric lavage and
emetics. A safe, effective, all-purpose anti-
dote is “two parts charcoal, one part tannic
acid, and one part magnesium oxide mixed
with water and followed by lavage and
purgation.”13 Central nervous system de-
pressants may be treated by the method
outlined above for acute alcoholism. Intra-
venous injection of 5 c. c. of coramine, 3 c.
c. of metrazol, or 1 c. c. of picrotoxin every
fifteen minutes until improvement is noted
is considered by Greene18 to be quicker, bet-
ter therapy than reliance on the dubious
analeptic effects of caffeine.

(5). Heat Stroke: Heat stroke may be
diagnosed on the history of exposure to
excessive heat and physical findings of in-
tensely hot, dry skin, fibrillary twitchings
of the muscles, and a temperature of 106°
or more.

Treatment : Treatment consists of lower-
ing the body temperature by undressing
the patient, wrapping him in an ice cold,
wet sheet and letting an electric fan play
across him. During this procedure, 2 to 5
grains of caffeine sodium benzoate should
be injected intramuscularly every three
hours, and an intravenous infusion of 5 per
cent glucose in normal saline started at

Saunders — Common Medical Emergencies

535

once and repeated every four to six hours.
Two c. c. of digalen may be injected intra-
venously every five or six hours, if the pulse
is extremely fast.17

(6). Heat Exhaustion : Severe heat ex-
haustion causes unconsciousness, delirium,
coma. The temperature is subnormal, the
skin cold and clammy, the respiration rapid,
and the pupils dilated.

Treatment : Wrap the patient in a light
blanket, place a hot water bottle at his feet
and start an intravenous infusion of 5 per
cent glucose in normal saline. One grain
of caffeine sodium benzoate injected sub-
cutaneously is useful as a respiratory stim-
ulant.17

ORGANIC INTRACRANIAL COMA

(1) . Brain Tumor and Abscess: The
immediate question in diagnosis of this
group of comas is whether or not to per-
form a lumbar puncture. If brain tumor is
suspected a spinal tap is contraindicated be-
cause of the great danger of impacting the
brain stem in the foramen magnum when
pressure is suddenly reduced from below
by withdrawal of spinal fluid. However,
brain tumors do not have the acute onset
which characterizes other lesions in this
group, and it is usually possible to obtain
from the patient’s family a history of slow-
ly progressive mental changes, with fre-
quent, throbbing headache and vomiting,
visual disturbances, difficulty in co-ordina-
tion and perhaps focal fits or other local-
izing signs.19 Since brain tumors are neu-
rosurgical problems, their treatment will
not be considered here.

Brain abscess is similar to brain tumor
in its symptomatology, except that the
course of abscess is more rapid and the
localizing signs less definite.19 It is a sur-
gical problem.

(2) . Skull Injury and Brain Trauma:
The diagnosis of skull injury can be made
on the history of an accident and the find-
ing of a fracture by physical examination
or by x-ray. Brain trauma is less readily
diagnosed and will probably require a thor-
ough work-up. In both cases, the patient
is apt to be in shock, which requires imme-
diate treatment without waiting for diag-

nosis. In addition to routine shock treat-
ment, 50 c. c. of 50 per cent dextrose should
be injected intravenously every six to eight
hours to combat cerebral edema.20 Further
treatment of skull injury is surgical. Fur-
ther treatment of brain trauma will be dis-
cussed with that of cerebrovascular hem-
orrhage.

(3). Meningitis and Encephalitis: If
Kernig’s and Brudzinski’s signs and stiff
neck are present, immediate lumbar punc-
ture is indicated. The spinal fluid pres-
sure is increased in cerebrovascular acci-
dent, meningitis and trauma, and, there-
fore, is of little help in differential diag-
nosis. If the fluid under increased pressure
is bloody, this points to a cerebrovascular
lesion or trauma.11 If it is purulent, men-
ingitis is probably the diagnosis. If it is
only slightly cloudy, encephalitis should be
considered. The final diagnosis of menin-
gitis can be made by finding bacteria, in-
creased protein level and cell count, de-
creased sugar and chloride levels, and no
blood in the spinal fluid. Encephalitis
causes pleocytosis in the spinal fluid; pro-
tein levels are normal and bacteria are not
present.

Treatment: Emergency treatment of

meningitic coma consists in immediate in-
travenous injection of 100 c. c. of a 5 per
cent solution of sodium sulfadiazine and the
reduction of increased intracranial pres-
sure, which can be effected at the time
diagnostic lumbar puncture is made. Lum-
bar puncture may have to be repeated in
six hours if the patient is still in coma, de-
lirium or acute discomfort because of high
intracranial pressure. Treatment of en-
cephalitis is entirely symptomatic. Repeat-
ed lumbar punctures and intravenous injec-
tion of 50 per cent glucose solution are in-
dicated to relieve increased intracranial
pressure. If the patient has repeated con-
vulsions in spite of the lowered pressure,
sodium amytal, 3 to 7V& grains by intra-
venous injection, is indicated. An indwell-
ing catheter with tidal drainage is advisable
for bladder paralysis. The patient should
be isolated, kept warm and given at least
3,000 c. c. of fluids a day.21

536

Saunders — Common Medical Emergencies

(4). Cerebrovascular Accidents : Hav-

ing eliminated other causes of coma, it is
now necessary to differentiate between ce-
rebral hemorrhage, cerebral embolism and
cerebral thrombosis. Cerebral hemorrhage
can be extradural, subdural, subarachnoid,
or intracerebral. The first three commonly
follow trauma. The last results usually
from disease of the cerebral vessels. Extra-
dural hemorrhage may be suspected if one
obtains a history of head trauma followed
by a return of consciousness, then by pro-
gressive coma later in the day. In the ab-
sence of a history, the diagnosis is sug-
gested by the presence of unilateral pupil-
lary dilatation, descending contralateral
convulsions followed by contralateral pa-
ralysis, greatly increased spinal fluid pres-
sure and absence of blood in the spinal
fluid.22 This condition is surgical and de-
mands an emergency trephine.

The presence of signs of increased intra-
cranial pressure, of clear, colorless spinal
fluid, without pleocytosis, but with in-
creased protein content, the absence of lo-
calizing signs, and a history of headache,
drowsiness, mental confusion and perhaps
of trauma, followed by a latent period of
days or months before onset of symptoms,
make the diagnosis of subdural hemorr-
hage.1!) Treatment is surgical.

Intracerebral hemorrhage, thrombosis
and embolism all cause hemiplegia, but
their manner of onset is usually sufficiently
different for diagnosis to be possible. In
intracerebral hemorrhage, which most com-
monly involves the internal capsule, un-
consciousness comes on suddenly, the pa-
tient’s face is flushed, his respiration often
Cheyne-Stokes in type, his blood pressure
increased, his pulse slow and full. He shows
conjugate deviation of the eyes toward the
side of the lesion, ipsilateral facial paraly-
sis and contralateral paralysis of the ex-
tremities, at first flaccid, then spastic;
the Babinski reflex on the paralyzed side is
positive.14 In pontine hemorrhage and
hemorrhage into the ventricles, paralysis
is frequently bilateral.23

The symptoms of cerebral thrombosis de-
velop more slowly than those of hemorr-

hage do. Prodromal dizziness, aphasia, and
mental confusion are often present. Hemi-
plegia takes a day or two to develop fully,
and coma may not occur until very late.23
The blood pressure is usually not elevated.

The onset of cerebral embolism is even
more sudden than that of cerebral hemorr-
hage, loss of consciousness is less common,
convulsions more common. The blood pres-
sure is usually not increased. Otherwise,
the signs and symptoms of hemorrhage and
embolism are identical.

Treatment: Treatment of these cerebral
accidents is largely supportive, and consists
of providing adequate rest, fluid intake and
elimination.23 Two to 4 c. c. of 25 per cent
solution of magnesium sulfate injected in-
tramuscularly every two hours, 25 to 30
grains of chloral hydrate in eight ounces
of milk by rectum, or small doses of bar-
biturates, may be used for sedation. Fif-
teen hundred c. c. of normal saline sub-
cutaneously and 1000 c. c. of 5 per cent
glucose solution intravenously will satisfy
the daily fluid requirements.

In the treatment of any comatose patient,
there are, according to Greene,18 special
precautions to be taken.

(1) . Urinary output must be main-
tained at a minimum of 1000 c. c. a day. A
retention catheter, 40 grains of a sulfona-
mide daily and the injection of 1 :2000 so-
lution of prostigmine every three hours for
five doses, are advised to prevent over-
distention and infection of the bladder.

(2) . Excessive intake of sodium must
be prevented. If 5 per cent glucose in
distilled water is alternated with saline as
an infusion fluid, enough free water will
be available for excretion of the excess
sodium, provided the patient’s kidney func-
tion is normal.

(3) . If shock, vomiting and profuse
bronchial secretions are absent, it is best
to keep the patient in a semi-sitting posi-
tion to inhibit development of pulmonary
edema.

(4) . The stomach should be kept empty
to lessen the danger of aspiration.

(5) . If partial respiratory obstruction
exists a mechanical airway is advisable.

Saunders — Common Medical Emergencies

537

(6) . Shock should be watched for and
treated immediately.

(7) . Oxygen is always necessary in any
coma. One hundred per cent oxygen is
beneficial and safe, if continued not more
than twelve hours at a time and if alter-
nated with four hours of 50 per cent
oxygen.

CARDIAC EMERGENCIES

Cardiac emergencies are perhaps the
most common crises in medical practice.
They include congestive heart failure, coro-
nary thrombosis, angina pectoris, tampo-
nade, and certain arrhythmias.

A. Congestive Heart Failure: This may
be either left-sided, right-sided or bilateral.
Primary left ventricular failure is three
times as common as primary right ventric-
ular failure. The causes of left heart fail-
ure are hypertension, narrowing or occlu-
sion of the descending branch of the left
coronary artery, aortic stenosis and aortic
regurgitation. The most common cause of
right heart failure is left heart failure;
mitral stenosis, chronic pulmonary fibrosis
and emphysema, and congenital pulmonary
stenosis, in this order, rank next in im-
portance. Thyroid disease, anemias, arrhy-
thmias, rheumatic carditis, generalized
coronary sclerosis, mitral regurgitation and
patent ductus arteriosus affect both sides
of the heart about equally.24®

Acute left ventricular failure may be
diagnosed on a history of acute paroxysmal
dyspnea, the presence of dyspnea and or-
thopnea (with or without pulmonary ede-
ma, bubbling rales, cough and blood-tinged
sputum), cardiac enlargement to the left,
and the absence of any signs of right ven-
tricular failure. When engorgement and
pulsation of the neck veins, enlarged, ten-
der liver, ascites, hydrothorax, hydroperi-
cardium, and edema are also present, the
failure is bilateral. When these latter find-
ings are present in the absence of dyspnea,
the condition is, obviously, primary right
ventricular failure. Cardiac asthma is a
“clinical syndrome of a paroxysmal, usually
nocturnal, attack of orthopnea with wheez-
ing respiration, due, in most instances, to
temporary failure of the left ventricle.”25

Treatment: Emergency treatment of all
forms of acute heart failure is essentially
the same, and entails prompt institution of
the following measures:

(1) . Put the patient at absolute bed
rest in an upright or semi-upright posi-
tion.24®

(2) . Administer morphine sulfate,
grain subcutaneously, unless Cheyne-Stokes
respiration is present. In cases of cardiac
asthma this dose may be repeated every 15
minutes for four doses, if necessary.25

(3) . If bronchospasm is present, atro-
pine sulfate, 1/150 grain subcutaneously is
of value.26

(4) . Oxygen inhalation, by nasal cathe-
ter, at the rate of six to eight liters a min-
ute, must be started immediately.25 The
use of an oxygen-helium mixture is a great
mechanical aid to respiration.24® If much
pulmonary edema is present, an oxygen tent
and a 95 per cent oxygen, 5 per cent carbon
dioxide mixture is strongly indicated.25

(5) . Digitalization must likewise be
started at once. If the patient is moribund
and is known to have received no digitalis
within the past two weeks, intravenous in-
jection of 1/120 grain of ouabain or stro-
phanthin is safe and expedient.24b This dose
may be repeated in twelve hours and then
once every day or two, if necessary. If
neither of these drugs is available, digitalis
in the form of Lanatoside-C, 1.5 to 2 mg.,
digitaline nativelle, 1.25 mg., or three am-
pules of digalen or digifolin may be given
intravenously.26 Each of these doses is
equivalent to three cat units of digitalis
leaf. One ampule of the digalen or digi-
folin may be given at three hour intervals,
if indicated.

If the patient’s condition is somewhat
less urgent and if he is able to take medi-
cines by mouth, digitalis leaf, 7*/2 grains
every eight hours for three doses, will ef-
fect rapid digitalization of the average
adult, weighing between 125 and 150
pounds.24® The general rule is that 11/2
grains of digitalis leaf per 10 pounds of
body weight, plus li/2 grains for each day
which elapses until digitalization is com-

538

Saunders — Common Medical Emergencies

plete, are required for maximum therapeu-
tic effect.

It is very important to determine wheth-
er the digitalis to be used has been assayed
according to U. S. P. XI or according to
U. S. P. X standards. If U. S. P. XI digi-
talis is used, 1 grain is equivalent to IV2
grains of the dosages given above.240 It is
also imperative to determine the previous
, status of the patient in regard to digitalis.
If accurate information cannot be obtained,
large doses of digitalis are strictly contrain-
dicated.20 Small doses and careful watch
for signs of toxicity are indicated.

(6) . If the patient shows no improve-
ment under the above treatment within an
hour, venesection should be considered.240
The rapid removal of 200 to 500 c. c. of
blood may be life-saving. Another way of
reducing the load on the heart is the Dan-
zer method of preventing venous return
from the limbs by means of blood pressure
cuffs inflated to a pressure slightly above
the diastolic pressure of the extremities.25

(7) . Diuretics are indicated when dysp-
nea and edema are not quickly relieved by
digitalization, oxygen and rest. Intra-
venous injection of 3% grains of amino-
phylline three times a day and 2 c. c. of
mercupurin or salyrgan every two or three
days will usually induce diuresis and reduce
edema in right heart failure.240 The amino-
phylline also has a very beneficial effect
on Cheyne-Stokes respiration and cardiac
asthma and “sometimes smoothes out the
breathing within a minute or two.”24a

(8) . Fluid intake should be limited to
1000 c. c. a day during the first few days,
until dyspnea and edema have been re-
lieved. Water, milk, soup, coffee, tea and
fruit juices are permissible. Carbonated
drinks are to be eschewed. Food should
likewise be restricted. A useful diet, which
restricts both food and fluid, is the Karell
diet, 200 c. c. of skimmed milk every six
hours for the first two or three days fol-
lowing congestive failure.243

(9) . One-half an ounce of magnesium
sulfate every day or two is often invaluable
in the management of edema.243

(10) . If cardiac asthma persists, respi-

ratory stimulants are indicated as adjuncts
to the above therapeutic measures. Cora-
mine, one ampule, or caffeine sodium ben-
zoate, 714 grains, injected intravenously,
may be tried.25 If bronchospasm is marked
and angina pectoris and coronary occlusion
have been definitely ruled out, epinephrine
in very small doses, 0.2 or 0.3 c. c., injected
subcutaneously, may be used to relax the
bronchial muscles.

B. Coronary Disease : I. Coronary occlu-
sion is most commonly caused by atheroma
of the coronary arteries. Less frequent
causes are syphilis, rheumatic and other
non-syphilitic infections, endarteritis oblit-
erans, embolism and congenital anom-
alies.243

Diagnosis can sometimes be made on the
basis of a history of previous angina pec-
toris or hypertension, the presence of se-
vere, agonizing substernal pain which radi-
ates to the back, neck, arms and epigastric
region, dyspnea and cyanosis, signs of
shock, faint heart sounds, gallop rhythm or
auricular fibrillation, apical systolic mur-
murs and an increased pulmonary second
sound. Friction rub, leukocytosis, fever
and increased sedimentation rate are later
findings. However, in many cases the signs
and symptoms are so equivocal that resort
must be had to electrocardiography.

Treatment : Leaman27 outlines the follow-
ing treatment for coronary occlusion :

(1) . Absolute bed rest, with as little
disturbance of the patient as possible.

(2) . Morphine sulfate, x/> grain, re-
peated in half an hour and every two or
three hours thereafter, as required. The
respiration rate serves as a guide to dosage.

(3) . Oxygen inhalation until the pa-
tient’s pain and cyanosis have disappeared.

(4) . Fifty c. c. of 50 per cent glucose,
injected very slowly into the vein, will pro-
vide food for the damaged heart muscle.

(5) . Aminophylline, 0.24 to 0.48 gram
intravenously, is sometimes beneficial in
increasing coronary blood flow.

(6) . Caffeine sodium benzoate, 71/2
grains subcutaneously, is helpful in shock.

Digitalis is contraindicated except in the
presence of congestive heart* failure.

Saunders — Common Medical Emergencies

539

White24b advocates the routine use of quini-
dine sulfate, 3 grains four times a day,
orally, to abolish or prevent arrhythmias.

II. Angina pectoris is diagnosed solely
on its symptomatology — the typical charac-
ter and radiation of the pain — and the cir-
cumstances which precipitate its onset.

Treatment : Treatment of the acute at-
tack consists in the administration of a
quick-acting nitrite. A nitroglycerine tab-
let, held under the tongue and allowed to
dissolve, is the drug of choice — so much so
that it is almost routine.

C. Cardiac Arrhythmias : These are of-
ten harmless, but if they complicate organic
heart diseases may constitute emergencies.
Furthermore, long uncontrolled tachycard-
ias may precipitate congestive heart failure
in a normal heart.

I. Auricular tachycardia is character-
ized by the abrupt onset of a regular heart
rate of 160 to 200 beats per minute, ac-
companied by symptoms of palpitation, ver-
tigo, and rarely syncope. These attacks
last a few minutes to a few hours or days
and stop as abruptly as they began.27

Treatment : (1). Firm pressure over

the right carotid sinus for a few seconds at
a time will abolish the paroxysm in 10 per
cent of cases.27

(2) . If carotid pressure is ineffectual,
vagal stimulation, by means of pressure on
the eyeballs or evoking the gag reflex or
oral administration of 2 to 4 drams of
syrup of ipecac may stop the tachycardia.27

(3) . Quinidine sulfate, 6 grains by
mouth at the onset of the attack, proves
effective in some cases.27

(4) . Subcutaneous injection of 1/2 to
2/3 grain of mecholyl is indicated in some
stubborn cases, 24b but is strongly contrain-
dicated in asthmatic patients.26

II. Ventricular tachycardia is rare in
the absence of serious fyeart disease.26 It is
characterized by a regular heart rate of
120 to 160 beats per minute, which usual-
ly starts abruptly, but which may be pre-
ceded by a series of premature beats. The
paroxysm stops as suddenly as it starts.
Carotid sinus pressure has no effect what-
ever on this type of tachycardia.27

Treatment : ( 1 ) . Quinidine sulfate is
the drug of choice in this condition. A test
dose of 3 grains by mouth should be given.
If no ill effects follow, the dose may be re-
peated every four hours during the first
day. If the paroxysms are not controlled
by this amount of quinidine, 6 grains every
four hours may be given the second day.27

(2). If the paroxysm is prolonged and
is not controlled by quinidine, the danger
of ventricular fibrillation justifies more
strenuous measures. Quinine dihydrochlo-
ride, 71/2 grains injected intramuscularly,
every two hours for several doses, is indi-
cated.241’

Digitalis is contraindicated in both forms
of tachycardia.

III. Auricular flutter is most commonly
found in hypertension, thyrotoxicosis, mi-
tral stenosis and coronary disease, but may
occur in normal hearts. It is usually char-
acterized by rapid regular auricular con-
tractions— 200 to 400 per minute — and reg-
ular ventricular contractions at one-half
the auricular rate, and by the long duration
of the attack. However, the heart rate may
be irregular because of varying degrees of
heart block. In these cases, electrocardi-
ography is necessary to make the diag-
nosis.2451

Treatment : Digitalis is the drug of
choice, the dose being 3 grains of standard
leaf three times a day for two or three days.
If auricular flutter continues after the ven-
tricular rate has been restored to normal,
the patient may be put on a maintenance
dose of 11/2 grains of digitalis a day, or a
course of quinidine sulfate may be tried.
White24a recommends a preliminary test
dose of 3 grains to rule out sensitivity, then
6 grains every four hours for five doses
a day, until flutter is abolished or until
the patient shows signs of cinchonism. If,
during digitalization, flutter is superseded
by fibrillation, sudden stoppage of the drug
may restore normal rhythm.

IV. Auricular fibrillation is most com-
mon in thyrotoxicosis, mitral stenosis and
arteriosclerosis, is infrequent in aortic val-
vular disease, luetic aortitis, bacterial endo-
carditis and congenital heart disease. It

540

Saunders — Common Medical Emergencies

occasionally results from toxic agents such
as alcohol, tobacco and acute infectious dis-
eases. It is diagnosed by the presence of
absolute cardiac irregularity, increased by
exercise and amyl nitrite, the presence of a
pulse deficit and the patient’s complaints
of severe, irregular palpitations.24*1

Treatment : (1). Absolute bed rest and
rapid digitalization, as outlined for the
treatment of congestive heart failure, are
the methods of choice in most cases of fib-
rillation.

(2) . If thyrotoxicosis is present, 5 to
10 drops of Lugol’s solution three times a
day supplement bed rest and digitalis. Ar-
rangements should be made for thyroid-
ectomy as soon as the patient is digi-
talized.25

(3) . Quinidine is indicated for those
cases of auricular fibrillation : (a) in young
individuals with no other signs of heart dis-
ease; (b) in individuals with minimal heart
disease and a short history of fibrillation;
(c) in hyperthyroid individuals, without
serious heart disease, in whom auricular
fibrillation persists several weeks after
thyroidectomy.28 The dosage is as outlined
above for flutter.

V. Adams-Stokes syndrome occurs as a
result of partial A-V block alternating with
periods of complete block.27 It is charac-
terized by syncope and a very slow pulse or
no pulse.

Treatment : Treatment is usually not pos-
sible, since the patient either recovers or
dies in a few minutes. However, if he has
a history of previous attacks of proved
Adams-Stokes syndrome, intracardiac in-
jection of 0.5 c. c. of 1:1000 epinephrine is
justified and may be life-saving.27

VI. Tamponade occurs in the course of
acute pericarditis and is the result of an
excessively large pericardial effusion. It
may be diagnosed by the patient’s com-
plaints of distressing dyspnea and thoracic
oppression, and by the presence of mark-
edly increased cardiac dulness, which
changes shape with change of position,
rapidly falling arterial pressure and pulse
pressure and rising venous pressure, para-
doxical pulse, engorged pulsating neck

veins, enlarged, tender liver, and positive
Ewart’s sign.

Treatment: Prompt paracentesis and

withdrawal of fluid from the pericardial
sac are imperative. The best site for para-
centesis is the fifth left interspace one or
two centimeters medial to the lateral bor-
der of cardiac dulness. Other sites which
may be tried if no fluid is obtained on the
first tap are : the fourth or fifth left inter-
space near the sternum, the fourth right
interspace near the sternum, the angle be-
tween the xiphoid process and the left
costal border, and the seventh or eighth
left interspace in the midscapular line.24a
The skin and subcutaneous tissues should
be anesthetized with 0.5 per cent procaine
before paracentesis is attempted.

PULMONARY 'EMERGENCIES

In addition to hemoptysis there are sev-
eral other pulmonary emergencies to be
considered : pulmonary infarction due to
embolism or thrombosis ; atelectasis, pneu-
mothorax, and acute pulmonary edema.

A. Pulmonary Infarction: This may be
caused by: (1) “any condition which pro-
duces toxins of such a nature as to injure
the intima of the vessels, or which places
an unusual strain on already damaged ves-
sels” ;2 (2) thrombophlebitis of the veins of
the extremities or other parts of the vena
caval system; (3) operative trauma; (4)
an embolus from the heart; (5) subacute
bacterial endocarditis; (6) puerperal sep-
sis; (7) pelvic inflammatory disease.23

The clinical findings in pulmonary in-
farction are sudden, sharp pain in the chest,
especially beneath the sternum, dyspnea,
cyanosis, pallor, anxiety, cold, clammy skin,
rapid, thready pulse, falling blood pressure.
Later findings are pleuritic pain, cough
with blood-streaked sputum, perhaps an
area of percussion dulness, moist rales and
bronchial breathing. Occasionally a car-
diac murmur or thrill may be heard over
the second left interspace.2 Another find-
ing which may prove of diagnostic value
is extreme tenderness to light direct or im-
mediate percussion or to very light fist
percussion over the infarcted area.29
White240 states that pulmonary infarction

Saunders — Common Medical Emergencies

541

“does not usually give rise to the old text-
book picture with blood spitting” and
should be suspected in any “otherwise un-
explained episode of chest discomfort, acute
breathlessness or pulmonary edema, of
tachycardia, cyanosis, fever or leukocytosis,
especially if repeated or if the patient has
had a leg injury.”

Treatment : If the patient is in shock,
treat the shock. Morphine *4 grain, should
be repeated as often as necessary to keep
the patient quiet. He must be at absolute
rest, with the head and shoulders elevated.
Oxygen at once is indicated.30 Splinting
the chest with adhesive tape may afford
some relief of the pleuritic pain.23 One
mg. per kilogram of body weight of heparin
may be given intravenously to prolong co-
agulation time. If the patient is in auric-
ular fibrillation, there is a good chance
that the right auricle is the source of his
pulmonary embolus ; in this event, quinidine
therapy should be begun at once in the
effort to control cardiac rhythm and so
prevent further embolism.31 If the patient
is in heart failure, digitalization must be
started to relieve pulmonary congestion. If
the patient survives the initial shock, and
if an experienced operating team is avail-
able, embolectomy may be considered as a
last resort.2

B. Atelectasis : The most important fac-
tor in the production of atelectasis is
bronchial obstruction, by thick mucus
plugs, foreign bodies, bronchiogenic new
growths,32 congestion secondary to infec-
tion with swelling of the mucosa, localized
infection of the bronchial wall, enlarged
hilar nodes, aneurysms, mediastinal tumor
masses,33 or neurogenic bronchial constric-
tion.2

Atelectasis causes sudden onset of
marked dyspnea and cyanosis, increased
pulse and respiration rate, rapid rise in
fever, cough and a feeling of apprehension
rather than pain on the part of the patient.
The important physical signs are dimin-
ished expansion of the chest, percussion
dulness, diminished or absent breath
sounds on the affected side, and shifting
of the heart toward the affected side.32

X-ray shows a dense, homogeneous shadow
occupying the area of one lobe or perhaps
the entire lung, elevation of the diaphragm,
depression of the ribs and narrowing of the
intercostal spaces on the affected side.

Treatment : Treat shock first. Once
shock is combatted it is necessary to remove
the bronchial obstruction. Rolling the pa-
tient from side to side, stimulation of the
cough reflex by forced inhalation of 5 per
cent carbon dioxide and 95 per cent oxygen
and postural drainage may succeed in re-
moving the obstruction.32 However, bron-
choscopy is a more certain method and
should be employed immediately if facili-
ties are available.2

C. Pneumothorax : Tuberculosis causes
about 70 per cent of spontaneous pneumo-
thorax. Other causes are lung abscess,
bronchiectasis, rupture of an emphysema-
tous bleb, hemorrhage, infarct and perfo-
rating wounds.

Sharp, excruciating, tearing pain, dysp-
nea, cyanosis, and signs of shock are the
outstanding symptoms of pneumothorax.
The physical signs of importance are ab-
sence of respiratory movements, diminution
or absence of tactile fremitus, tympanitic
percussion note, absent breath sounds and
vocal fremitus on the involved side, and
mediastinal shift toward the good side.
Succussion splash, metallic tinkle, and the
coin sign are pathognomonic of pneumo-
thorax when present, but are often absent.2

Treatment : Treat the shock. If respira-
tion and heart action are severely embar-
rassed by the mediastinal shift, aspiration
of enough air to relieve the acute symptoms
is imperative.31

D. Acute Pulmonary Edema : Acute pul-
monary edema may result from cardiac
failure, particularly left ventricular failure,
from pneumonia, lung abscess, acute pul-
monary tuberculosis, and from the inhala-
tion of noxious gases such as ammonia,
nitric and nitrous acid, and chlorine.

The clinical picture is one of severe
dyspnea and cyanosis, cough with expecto-
ration of masses of frothy, bloody sputum,
and coarse, bubbling rales, which may be
heard without use of the stethoscope. In

542

Saunders — Common Medical Emergencies

late cases percussion dulness and increased
vocal fremitus may be detected.

Treatment : Treatment depends on the
cause of the edema. If cardiac failure is
the cause, it should be treated as previously
outlined. Treatment of shock and sympto-
matic relief of dyspnea and cyanosis by
inhalation of oxygen and helium are indi-
cated for primary lung conditions. If a
noxious gas has been inhaled, the patient
should, of course, be given oxygen inhala-
tions immediately.2

E. Asphyxia: Asphyxia results from
drowning, electric shock, bronchial obstruc-
tion, poisonous gases, anesthetics, and nar-
cotics. The early stages are accompanied
by increased respiration and pulse rates,
elevated blood pressure and flushing of the
skin. Later, respiration becomes enfeebled,
the pulse is thready. Finally, coma and
convulsions ensue.

Treatment : Prompt artificial respira-
tion, with oxygen and carbon dioxide in-
halation, if possible, must be started at once
and continued as long as the patient’s heart
continues to beat. Henderson and Turner35
advocate the Shaefer prone pressure meth-
od, which has the great advantage that it
requires no special equipment. However,
this method depends to a large extent on
the presence of normal tonus in the re-
spiratory muscles, which tonus may be lack-
ing in late cases of asphyxia. In this event,
positive-negative resuscitation with an Em-
erson respirator, using pressures of plus 15
and minus 15 mm. of mercury, may prove
effective where manual methods have
failed.36

RENAL EMERGENCIES

The most important medical emergencies
of renal origin are uremia, anuria follow-
ing sulfonamide therapy, and hemoglobinu-
ria resulting from transfusions and acute
malaria. Other renal emergencies, such as
acute urinary retention, renal colic, and
anuria due to stones, are primarily urolog-
ical problems and will not be considered
here.

A. Uremia : Uremia is divisible into
two types, true uremia and pseudo-uremia,
or hypertensive encephalopathy. The for-

mer is the end stage of chronic nephritis
and supervenes when the last reserves of
kidney function have been exhausted. The
latter occurs in the course of acute glomeru-
lonephritis, hypertension and toxemias of
pregnancy. This distinction is important
prognostically and diagnostically, and, to a
less extent, therapeutically.

True uremia may be diagnosed on the
following findings:

(1) . A history of chronic kidney disease,
of headache, muscular weakness, somno-
lence, nausea, vomiting, diarrhea, oliguria,
dyspnea and pruritus.

(2) . The presence of pallor, emaciation,
muscular twitching, delirium or coma,
Kussmaul or stertorous breathing, and a
urinous odor on the breath.

(3) . Low specific gravity of the urine
(less than 1.020) and elevated NPN, crea-
tinine, indican, phosphate and sulfate levels
in the blood, and decreased carbon dioxide
combining power.

Psuedo-uremia may be differentiated by
the finding of convulsions rather than
coma, elevated blood pressure, amaurosis,
signs of increased intracranial pressure
and a normal or only slightly elevated NPN
blood level.37

Treatment : (1). The constant patho-

logic conditions in true uremia which must
be combatted promptly are oliguria or anu-
ria, azotemia and acidosis. In addition,
edema, convulsions and cardiac embarrass-
ment may complicate the picture. The pres-
ence of edema is a particular problem, in-
asmuch as forcing fluids to induce diuresis
is almost certain to aggravate the edema.
However, in the presence of a failing kid-
ney and rapidly rising NPN, fluids should
be forced up to 2000-2500 c. c. a day.38 If
the patient is dehydrated, a total of 4000
c. c. may be necessary. Five per cent or 10
per cent glucose solution is best if the pa-
tient is edematous; if not, glucose in saline
may be used. All routes of administration
— oral, subcutaneous, intravenous and rec-
tal— should be employed.

(2). If edema is present, salt intake
should be limited to 4 to 6 grams a day.38
But if the patient has developed hypochlore-

Saunders — Common Medical Emergencies

543

mia from vomiting, or if he is in the late
stages of chronic nephritis when the am-
monia-forming power of the kidney is much
impaired, salt restriction is an added drain
on the blood base content and should not
be attempted.37

(3) . Strong mercurial diuretics are
dangerous because their increasing concen-
tration in the blood — due to poor kidney
function — may cause poisoning. Amino-
phylline, 1$'! grains three times a day, may
be of some value in improving the general
circulation and secondarily inducing diu-
resis.37 Murphy38 and Derow39 advocate
the use of intravenous infusions of 400 to
500 c. c. of 20 per cent acacia solution in
the presence of nephrotic edema, since this
elevation of the colloid osmotic pressure
of the blood facilitates withdrawal of edema
fluid from the tissues and often initiates
diuresis.

(4) . Diathermy has a very beneficial
effect on kidney function in many cases. It
“seems to act in the same manner as de-
capsulation of the kidney”10 to stimulate
diuresis. In addition, deep heat induces
profound diaphoresis, which provides an-
other channel for elimination of edema
fluid and may, as a result of superficial
vasodilatation, improve exchange between
the blood and the tissues.37

(5) . Fishberg37 advocates saline or other
cathartics to keep the bowels open as an-
other avenue of escape for nitrogenous
waste products.

(6) . The presence of acidosis requires
prompt administration of base in some
form. Four hundred to 500 c. c. of 5 per
cent sodium bicarbonate solution may be
given intravenously. The disadvantage of
this solution is that it cannot be sterilized,
therefore Hartmann’s solution, which is
stable to boiling, is preferable. Since aci-
dotic signs and symptoms do not appear
until carbon dioxide combining power of
the blood is less than 20 volumes per cent,
the empiric dose of Hartmann’s solution is
60 c. c. per kilogram of body weight, which
amount will raise the carbon dioxide com-
bining power 33 volumes per cent.

(7) . Convulsions are caused by in-

creased intracranial pressure. They may
be managed in several ways: (a) By lum-
bar puncture and slow withdrawal of fluid ;
(b) by slow intravenous injection of 20 c. c.
of 10 per cent magnesium sulfate or 50 c. c.
of 50 per cent sucrose40 or glucose38 solu-
tion. Repetition of the convulsive seizures
can usually be prevented by hypodermic in-
jection of 1/4 grain of morphine or intra-
venous injection of 5 to 7 grains of sodium
amytal twice a day if necessary. If these
remedies are ineffectual, 40 grains of
sodium bromide, or ounce of paraldehyde
by rectum two or three times a day may be
necessary.38

(8). The cardiac status of the patient
must be carefully watched, and digitaliza-
tion started when dyspnea, rising pulse
rate, cyanosis or rales at the lung bases are
found. Murphy38 recommends l1/^ grains
of digitalis, injected intravenously four
times a day.

Treatment of pseudo-uremia differs from
the above methods in only one respecD— the
matter of forcing fluids. As long as the
NPN level of the blood is normal or nearly
so, forcing of fluids is not indicated at first,
since the urinary volume usually increases
spontaneously in a few days and early forc-
ing of fluids may precipitate acute pulmo-
nary edema.37 However, if oliguria be-
comes more marked, or if anuria develops,
drastic measures for the induction of diure-
sis are indicated. If these measures do not
relieve anuria within eighteen hours, decap-
sulation of the kidneys should be contem-
plated.38

B. Anuria Following Sulfonamides : Be-
ginning anuria resulting from sulfonamide
therapy may be diagnosed by the decrease
in urine output and the presence of red
blood cells, sulfonamide crystals and casts
in the urine.

Treatment : Treatment consists in imme-
diate stoppage of the drug and institution
of the procedures outlined above for stimu-
lation of diuresis. Diathermy is particu-
larly valuable in these cases.43 If anuria
persists in spite of everything, a urologist
should be called in to perform cystoscopy
and ureteral catheterization. However, ac-

544

Saunders — Common Medical Emergencies

cording to Hellwig and Reed,1- sulfadiazine
acts as a tubular poison, not by mechanical
blockage of the tubules with sulfonamide
crystals. Therefore kidney lavage is com-
pletely useless and ineffective in these
cases. Kidney decapsulation is the last re-
sort.

C. Hemoglobinuria: Hemoglobinuria re-
sulting from transfusion reactions or from
blackwater fever may be diagnosed by spec-
troscopic examination of the urine, which
in most cases is found to be grossly bloody.
If a spectroscope is not available, the benzi-
dine test will confirm the presence of blood
pigment in the urine, and this, with a his-
tory of malaria, blackwater fever, or trans-
fusion, and the presence of oliguria or anu-
ria is sufficient evidence for the diagnosis.

Treatment : Here again the problem is to
reestablish kidney function so that urine
flow will wash the blood pigment out of
the kidney tubules. Dove43 outlines the fol-
lowing treatment for hemoglobinuria re-
sulting from blackwater fever and mala-
ria :

(1) . Put the patient at complete bed
rest, with warm covers. Give him nothing
by mouth.

(2) . Start an intravenous infusion of 5
per cent glucose in saline immediately. Give
the first 1000 c. c. rather rapidly, the sec-
ond 1000 c. c. more slowly.

(3) . Give repeated small doses of mor-
phine sulfate for pain and restlessness.

(4) . After the paroxysm has passed
and the urine has cleared, give magnesium
sulfate orally as soon as it can be retained.

(5) . If the patient’s condition is no bet-
ter following glucose infusions, blood trans-
fusion is indicated.

(6) . If the patient is still unimproved
following transfusions, intramuscular in-
jection of 1 1/2 grains of atabrine every four
hours for three doses should be tried.

Medical treatment of anuria following
transfusion reactions includes the adminis-
tration of intravenous fluids, the use of
diathermy over the kidneys, and transfu-
sion of compatible blood. In addition,
there are several rather simple procedures
which should be tried before resort is had

to decapsulation or to irrigation of the re-
nal pelves. Spinal anesthesia has proved ef-
fective in a number of cases.44 Splanchnic
block has also brought about recovery of
the patient in several instances where other
treatment has failed.45

Treatment of renal emergencies may be
summarized as an attempt to reestablish
urine secretion by any method available. If
one method fails, another should be tried
promptly because the patient will surely die
if kidney function is not resumed in a few
hours.

ENDOCRINE EMERGENCIES

A. Diabetic Coma: Diabetic coma is the
most common of endocrine emergencies. It
presents a well marked syndrome, the out-
standing features of which are as follows :
a history of nausea and vomiting, anorexia,
diuresis, weight loss, extreme thirst, drow-
siness, and, frequently, abdominal pain ;
physical findings of cool dry skin, florid
facies, soft eyeballs, Kussmaul breathing,
very low blood pressure, rapid pulse, and
acetone odor on the breath ; laboratory find-
ings of greatly elevated blood sugar, great-
ly decreased carbon dioxide combining pow-
er, elevated NPN level in the blood, leuko-
cytosis, ketonuria and glycosuria.46 Diag-
nosis can be made on the history, physical
examination and urinary findings, without
waiting for the results of blood sugar tests.
Gerhardt’s diacetic acid test is considered
by Joslin46 to be the most reliable test for
emergency use.

Treatment : (1). A preliminary subcu-
taneous dose of 20 to 100 units of crystal-
line insulin should be given as soon as the
diagnosis is made — the actual amount de-
pending on the size of the patient, the de-
gree of acidosis and previous injections of
insulin administered en route to the hospi-
tal. Following this initial dose, subsequent
doses should be varied in accordance with
variations in either the blood sugar level
or urine sugar level. Blood sugar is the
more reliable index and is to be preferred
if laboratory facilities for running the test
exist. The average blood sugar level at the
onset of diabetic coma is about 500 mg. per
cent. A second determination should be

Saunders — Common Medical Emergencies

545

made two to three hours after the initial
injection of insulin. If the blood sugar lev-
el has not fallen, the initial dose of insulin
should be repeated; Olmsted47 recommends
100 units of regular insulin under these cir-
cumstances. If the level has fallen to
around 350 mg. per cent, the dose may be
reduced to 50 or 60 units. This process
of testing blood sugar and varying the in-
sulin accordingly must be repeated every
two hours until the diabetes is under con-
trol.

If blood sugar determinations are not
possible, frequent tests of urine sugar
should be made. Joslin46 suggests testing
the urine every half hour and giving 20
units of insulin for orange-red, 15 units for
yellow, and 10 units for yellow-green urine.
This procedure necessitates the introduc-
tion of an indwelling catheter into the
bladder.

(2) . One thousand c. c. of normal sa-
line should be given intravenously at once,
and hypodermoclysis of normal saline be-
gun, and continued as long as subcutaneous
fluid is rapidly absorbed.46

(3) . According to Joslin,46 alkalis are
dangerous and unnecessary at the outset of
treatment. However, if, after the diabetes
is under control, the carbon dioxide com-
bining power of the blood remains de-
pressed, Hartmann’s fortified lactate Rin-
ger’s solution should be given intravenous-
ly.47 This mixture consists of 60 c. c. of
1/6 molar lactate and 40 c. c. of Ringer’s
solution per 100 c. c. ; 500 to 1000 c. c. may
be infused, depending on the plasma bicar-
bonate level.

(4) . Gastric lavage with warm water
or normal saline should be done routinely,
as soon as possible.46 After an hour, or-
ange juice and/or ginger ale, in amounts
of 100 c. c. an hour, may be administered
by stomach tube if the patient is uncon-
scious, or orally if the patient is able to
cooperate. One hundred grams of carbo-
hydrate during the first 24 hours should be
given by the oral route if possible.

(5) . Cleansing enemas are also routine
in Joslin’s scheme of therapy.46 Fluids may

be administered by rectum following this
procedure.

(6) . The indications for intravenous
administration of glucose are : (a) a carbon
dioxide combining power of less than 40
volumes per cent in the presence of a con-
trolled blood sugar level and nausea; (b)
rapidly falling systolic blood pressure. In
the former instance, 500 to 1000 c. c. of 5
per cent glucose in saline solution twice a
day are indicated. In the latter instance,
10 per cent glucose infusion should be start-
ed while the patient’s blood is being typed
and donors secured for blood transfusion.
For every gram of glucose given intraven-
ously, 1 to 114 units of insulin should be
added to the infusion.46

(7) . Transfusions are indicated when,
in spite of routine treatment, the patient’s
blood pressure remains depressed. Joslin46
sets 70 mm. of mercury as the critical level
of systolic pressure.

(8) . If the patient is in uremia, 60 c. c.
of 10 per cent salt solution should be given
intravenously to stimulate diuresis.

Treatment along these lines must be con-
tinued until the diabetes and acidosis are
completely under control.

B. Hypoglycemic Shock : Hypoglycemic
shock is the anthithesis of diabetic coma.
It may result from either over-dosage of in-
sulin or a tumor of the islands of Langer-
hans. The important differentiation to be
made here is between hypoinsulinism and
hyperinsulinism. Diagnosis of hyperinsu-
linism can be made on the history of sud-
den onset of faintness, weakness, irritabili-
ty, tremor and sweating and extreme hun-
ger, especially after exercise ; physical find-
ings of pallor, apathy, moist skin, firm eye-
balls, normal respiration, blood pressure
and pulse rate ; laboratory findings of very
low blood sugar and freedom of the urine
from sugar.

Treatment : Treatment includes the im-
mediate administration of glucose by the
most convenient route. If the patient is
conscious and able to swallow, sugar, corn
syrup, molasses or honey may be given
orally. If the patient is unconscious, hypo-
dermic injection of 10 to 15 minims of

546

Saunders — Common Medical Emergencies

1:1000 epinephrine solution may rouse him
sufficiently so that he is enabled to take
fluids by mouth; if not, intravenous infus-
ions of 10 per cent glucose solution should
be given until the patient regains conscious-
ness:48 4 c. c. of 1:1000 epinephrine should
be added to every liter of solution.40

C. Addisonian Crisis : Addisonian crisis

presents the clinical picture of Addison’s
disease plus shock. The important diag-
nostic findings are: (a) The history of

anorexia, nausea, vomiting, asthenia,
weight loss and epigastric distress over a
period of months or years, and the pres-
ence of some precipitating factor such as
upper respiratory infection, overexertion,
purgation or salt deprivation ; (b) physical
findings of the characteristic pigmentation,
hypotension, emaciation, muscular flaccid-
ity, rapid feeble pulse, cold pale dry skin,
dry tongue, acetone odor on the breath, and
a state of coma or semi-coma.49

Treatment : (1). The patient should be
put to bed immediately and covered with
blankets.

(2) . Intravenous infusions of 1.5 per
cent sodium chloride and 5 per cent glucose
solutions at once, are imperative. A total
of 1000 c. c. of each solution should be given
during the first twelve hours.

(3) . Twenty-five c. c. of adrenal corti-
cal extract intravenously must be given
at once.

(4) . Another 25 c. c. of adrenal cortical
extract should be given subcutaneously.
This will begin to take effect in two to six
hours.

(5) . Twenty-five mg. of desoxycorticos-
terone acetate in oil, injected intramuscu-
larly in divided doses, will begin to act in
about 24 hours.50

(6) . Five hundred to 1000 c. c. of nor-
mal saline and an equal amount of 5 per
cent glucose solution are indicated during
the second 24 hours of treatment.

Under this regimen, the patient usually
feels reasonably well within 24 hours, after
which a program of long-term control of his
disease may be begun.

D. Thyroid Crisis : Thyroid crisis is a
serious complication of hyperthyroidism

which may occur spontaneously or after
physical or psychic trauma, infection or
operation.

In the presence of known thyroid disease
or findings characteristic of hyperthyroid-
ism, the onset of nausea, vomiting, diarr-
hea, rising temperature and heart rate,
marked restlessness and apprehension, and
beginning delirium signals a thyroid crisis.

Treatment : Treatment is directed toward
controlling the extreme hyperpyrexia,
which usually accompanies this condition,
by means of ice packs and ice water en-
emas,51 and toward supplying inorganic
iodide “to act as a buffer, thereby prevent-
ing liberation of organic iodine into the
blood stream;”52 2 to 4 grams of sodium
iodide a day, injected intravenously, may be
given for this latter purpose.

Glucose and saline infusions and nasal
oxygen are indicated for their supportive
effect. One of the bartiturates should be
given as necessary to calm the patient. If
there are any signs of beginning cardiac
involvement, digitalization is indicated.

E. Parathyroid Tetany : Parathyroid

tetany53 in its acute form usually occurs
after thyroidectomy, in the course of severe
infections, pregnancy or menstruation, or
after cessation of treatment for hypopara-
thyroidism.

Diagnosis of the hypoparathyroid state
may be made on the classical signs and
symptoms of tetany — Trousseau’s, Erb’s
and Chvostek’s signs, with or without gen-
eralized convulsions, muscular rigidity,
opisthotonus, stridor and dyspnea. The
serum calcium is usually low, but this is
not invariable since the “symptom thres-
hold” of some individuals may be so low
that convulsions occur in the presence of a
serum calcium level of more than 9 mm.
per cent.

Treatment: The object of therapy is to
restore normal blood calcium and phospho-
rus levels as soon as possible.

(1) . Calcium gluconate or chloride, 10
c. c. of a 10 per cent solution, should be
injected intravenously, and, if necessary,
repeated every two to four hours.

(2) . From 10 to 50 units of parathyroid

Saunders — Common Medical Emergencies

547

hormone should be injected subcutaneously
at once, the size of the dose depending on
severity of symptoms. Effects of the hor-
mone take 24 hours to appear and last about
20 hours. Further dosage must be gauged
by the patient’s response and by daily de-
termination of the blood calcium level.

(3). If the patient is extremely excited
and hyperirritable, a sedative of some kind
may be necessary.

EMERGENCIES DUE TO ALLERGY

The allergic phenomena which constitute
medical emergencies are acute bronchial
asthma and status asthmaticus, serum
shock and angioneurotic edema of the
larynx.

A. Acute Bronchial Asthma: Acute

bronchial asthma may be diagnosed by the
presence of intense dyspnea, cyanosis and
assorted rales in an individual with a his-
tory of previous similar attacks or of other
allergic manifestations. If the patient is
in the process of his first, attack, the possi-
bility of foreign bodies, cardiac asthma,
tracheal cancer, laryngeal gumma, aneu-
rysms or tumors must be considered. Tra-
cheal cancer causes a peculiarly high-
pitched wheeze, breath sounds are normal
and no rales are heard over the lung fields.
Gumma of the larynx likewise causes no
modification of breath sounds and no pul-
monary rales. Foreign bodies can usually
be ruled out by the history. Cardiac asthma
can be ruled out by the history and by the
appearance of the sputum, which is thin,
foamy and either white or blood-tinged,25
whereas the sputum in bronchial asthma is
thick, tenacious and stringy.

Treatment : (1) . Epinephrine is the most
useful of all drugs in this condition.54 The
dose is 0.2 to 0.3 c. c. of 1:1000 solution
injected subcutaneously. This treatment
usually brings relief within a few minutes,
but, if not, may be repeated at hourly inter-
vals for several doses, provided the patient
shows no untoward symptoms, such as
pallor, tremor and palpitation.

(2). Aminophylline, 3 and % grains in
10 c. c of water,55 injected intravenously,
has a direct dilating effect on the bronchial

muscles and may be used either alone or in
conjunction with epinephrine.

(3) . Potassium iodide is indicated at
the onset of the asthmatic attack to liquefy
the thick, tenacious bronchial secretion.
Wilson recommends the following prescrip-
tion :

Potassium iodide 10.

Elixir of lactopep 120.

Sig : one teaspoonful every three hours.

(4) . Inhalation of the smoke from a
2:1 mixture of potassium nitrate and stra-
monium is frequently very effective in re-
laxing the bronchioles.

(5) . The patient should be placed on a
simple diet, with care to exclude all known
allergenic foodstuffs.

Occasionally the patient will not respond
to any of the above measures. His attack
drags on for days; his respiratory distress
remains acute. This condition is known
as status asthmaticus and requires further
therapy.

(6) . Inhalation of 20 per cent oxygen
and 80 per cent helium mixtures provides
marked symptomatic relief of dyspnea.

(7) . Sedation is required, since the pa-
tient is in a state of exhaustion, yet cannot
rest. Chloral hydrate, 10 to 30 grains by
mouth,55 paraldehyde, 10 c. c. in 60 c. c. of
olive oil by rectum, or 0.2 gram of pheno-
barbital by mouth,54 may provide the nec-
essary rest. If not, general anesthesia must
be resorted to. Avertin, 60 mg. per kilo-
gram of body weight, or 75 to 100 c. c. of
ether in an equal amount of olive oil, may
be given by rectum. Morphine is contra-
indicated because of its depressing effect
on respiration.54

(8) . Slow intravenous infusion of 1500
c. c. of 5 per cent glucose in normal saline
is indicated in these severe cases, to provide
both food and fluid. In many cases, these
infusions also bring remarkable sympto-
matic relief.55

(9) . In cases which do not respond, the
slow, intravenous injection of 0.1 c. c. of
1:1000 epinephrine solution in 1 c. c. of
normal saline may be risked. This is a
dangerous procedure and is undertaken
only as a desperation measure.

548

Saunders — Common Medical Emergencies

B. Serum Shock : Serum shock results
from the injection of foreign protein to
which the individual has become sensitized
by previous exposure. It occurs within a
few minutes of the second injection of anti-
genic material, and presents a frightening
picture. In some cases, the patient experi-
ences sudden apprehension and respiratory
distress, many gasp or cry out. Dyspnea
and cyanosis develop rapidly, the patient
sinks into a coma and may die within a
few minutes. In other cases, other allergic
phenomena, such as itching, urticaria, vom-
iting and diarrhea, manifest themselves.

Treatment: (1). Place a tourniquet

above the injection site to delay absorption
of the antigen.

(2) . Inject 0.5 c. c. of 1:1000 epine-
phrine into another extremity at once.

(3) . If the serum has been given
intradermally, infiltrate the site with epine-
phrine to block lymph drainage.

(4) . If respiration is acutely embar-
rassed, artificial respiration and oxygen in-
halation are urgently indicated.

(5) . In very severe cases, intravenous
injection of 0.2 to 0.3 c. c. of epinephrine is
advisable.54

(6) . If the patient does not respond to
epinephine, ephedrine sulfate may prove
effective, especially in prolonged cases. It
can be given orally in doses of 50 mg., or
25 mg. can be added to 1000 c. c. of 10 per
cent glucose and administered by intraven-
ous infusion.50

(7) . If all of the above measures fail,
and if the patient’s blood shows hemocon-
centration, intravenous infusions of normal
saline solution may succeed in breaking the
vicious cycle.30

C. Angioneurotic Edema : Angioneuro-
tic edema, when it involves the larynx, is
a serious emergency, as the patient will
suffocate in a few moments if the obstruc-
tion is not promptly removed. The symp-
toms of laryngeal edema are gasping respi-
ration or complete apnea, intense cyanosis,
dysphagia and odynophagia.

Treatment: In moderately severe cases,
topical application of epinephrine to the
swollen larynx by means of a spray, plus

subcutaneous injection of the same drug,
may be effective in relieving obstruction.
In severe cases, where death is imminent,
tracheotomy or intubation must be done.54

GASTROINTESTINAL EMERGENCIES

Gastrointestinal emergencies are predom-
inantly surgical. The internist’s responsi-
bility is largely a matter of diagnosis,
which has been so thoroughly and concisely
covered by Hardy57 that it would be pre-
sumptuous to attempt further simplifica-
tion of the problem. However, there are a
few points in emergency treatment which
must be briefly discussed.

A. Ruptured Peptic Ulcer C (1). Enough
morphine sulfate to relieve the patient’s
pain is absolutely necessary. This may
require 1/2 grain or more.

(2) . Prompt intubation and continuous
gastric suction are urgently indicated to
prevent further spillage of intestinal con-
tents into the peritoneal cavity.

(3) . The patient is usually in shock,
which must be treated promptly by the
usual methods.

(4) . Placing the patient on his left side
may localize the peritonitis and prevent
development of subhepatic abscess.

B. Acute Pancreatitis: Acute pancreati-
tis is not properly a surgical emergency,
except in the fulminating hemorrhagic
type. The majority of cases are not ful-
minating and fare much better under med-
ical treatment than they do after operation.
If those deaths, which occur within 24 hours
after operation, are included, the surgical
mortality rate is 75 per cent, whereas the
medical mortality rate is slightly under 25
per cent.58

Treatment : ( 1 ) . Large doses of mor-

phine are required to control the pain,
wdiich is characteristically resistant to mor-
phia.

(2) . An indwelling duodenal suction
tube must be inserted and left in place dur-
ing the acute stage of the disease.

(3) . Hot stupes on the abdomen and a
rectal tube are indicated for relief of ob-
struction.

(4) . Transfusions of plasma and whole

Saunders — Common Medical Emergencies

549

blood must be given if the patient is in
shock.

(5) . Enough intravenous 5 per cent
glucose in saline solution should be given to
maintain urinary output at 1000 c. c. a day.
The necessary intake will vary with the
amount of fluid lost by vomiting.58

(6) . Fifteen to 20 units of insulin for
every liter of glucose solution are advisable,
because many of these cases are compli-
cated by impaired carbohydrate metab-
olism.10

C. Acute Diverticulitis of the Colon :
Operation is contraindicated in uncompli-
cated diverticulitis.10 Medical treatment
will afford symptomatic relief in 67 per
cent of cases59 and prepare the patient for
elective surgery after the acute stage has
passed.

Treatment : (1). The patient should be
put at bed rest and his colon rested by the
use of parenteral fluids.59

(2) . Laxatives and cathartics are
strongly contraindicated, but warm enemas
of 0.5 to 1 per cent magnesium sulfate are
beneficial.

(3) . Atropine sulfate should be pushed
to the limit of tolerance to relax intestinal
spasm. The initial dose is 1/250 grain,
which may be repeated every two hours
until response is noted.10

(4) . Codeine sulfate, i/2 grain, is useful
to give immediate relief from discomfort.

D. Acute Dilatation of the Stomach,
Major Pyloric Obstruction and Upper In-
testinal Obstruction : These conditions re-
quire immediate decompression by indwell-
ing suction tubes and reestablishment of
fluid and electrolyte balance by means of
intravenous infusions of glucose and sa-
line.10 This treatment will, if begun prompt-
ly, cure dilatation of the stomach00 and will
make the patient with pyloric or small
bowel obstruction a much better surgical
risk.

E. Acute Cholecystitis: Patients first
seen in the “danger period” of acute chole-
cystitis, from the second to the seventh
day, are temporarily medical problems.61

Treatment:10 ' (1). Complete bed rest is
necessary.

(2) . Morphine sulfate, % grain as
needed to control pain, is indicated.

(3) . Codeine sulfate, V2 grain, extract
of belladonna, 1/12 grain, and acetylsali-
cylic acid, 5 grains, every three to six hours,
often control moderate pain.

(4) . Flaxseed poultices to the abdomen
for one hour out of every six hours may
provide some relief from pain.

(5) . Low fat, high protein and carbo-
hydrate diet, if the patient is able to toler-
ate food by mouth, or intravenous infus-
ions of 10 per cent glucose in normal saline,
to the amount of 2000 to 3000 c. c. a day,
are necessary.

(6) . Bland enemas are indicated to
stimulate bowel movements.

(7) . Vitamin K, 1 to 2 mg. orally or
intramuscularly every two hours, is indi-
cated if the prothrombin time is less than
50 per cent.

SUMMARY

An attempt has been made to outline the
important diagnostic points and immediate
treatment of some of the most -common
medical emergencies. A brief recapitula-
tion of suggested methods of therapy fol-
lows :

1. Shock must be treated by large doses
of morphine, plasma infusion, oxygen in-
halation and cautious application of heat.

2. The general principles of treatment
of hemorrhage are rest and sedation of the
patient, hemostasis, and replacement of lost
blood. In intracranial hemorrhage, opera-
tion is required in some cases, and meas-
ures to reduce increased intracranial pres-
sure are often necessary.

3. Acute alcoholic coma requires imme-
diate gastric lavage, respiratory stimula-
tion and artificial respiration in severe
cases.

4. Status epilepticus is treated by seda-
tion and intravenous fluids to combat ex-
haustion.

5. Treatment of drug poisoning depends
on the nature of the toxic agent. For
gaseous poisons, fresh air, artificial respi-
ration and oxygen inhalation are indicated.
Ingested poisons must be removed by means
of gastric lavage and emetics. Analeptics

550

Saunders — Common Medical Emergencies

are indicated for the treatment of poisoning
by central nervous system depressants.

6. Anti-pyrexial measures and intra-
venous fluids are the mainstays of treat-
ment for heat stroke.

7. Heat exhaustion requires warmth
and intravenous fluids.

8. Brain tumor, brain abscess, and skull
injury are surgical problems.

9. Sulfonamides and measures to re-
duce intracranial pressure are urgently
needed in cases of meningitis.

10. In the management of any coma-
tose patient, the special precautions which
must be taken are to maintain kidney func-
tion, prevent excessive sodium intake,
guard against pulmonary edema and shock.

11. Absolute bed rest, morphine, oxy-
gen inhalation, digitalization, administra-
tion of diuretics for edema, and atropine
sulfate or aminophylline for bronchospasm
are the essentials in treatment of congestive
heart failure.

12. Absolute bed rest, morphine, oxygen
and aminophylline are likewise indicated
for treatment of coronary occlusion. Digi-
talis is contraindicated unless congestive
heart failure is also present.

13. Nitrites in some form are specific
for angina pectoris.

14. Quinidine sulfate is the drug of
choice for prolonged auricular or ventric-
ular tachycardia.

15. Digitalis is the drug of choice for
auricular flutter and fibrillation in the ma-
jority of cases, but quinidine may be indi-
cated under some circumstances.

16. Intracardiac injection of epine-
phrine may be lifesaving in Adams-Stokes
syndrome, but the opportunity for such dra-
matic treatment rarely presents itself.

17. Cardiac tamponade demands imme-
diate paracentesis and withdrawal of fluid
from the pericardial sac to relieve compres-
sion.

18. Pulmonary emergencies are usually
accompanied by shock, which must be
treated promptly. Oxygen inhalation is also
routine in all these cases. Further treat-
ment of infarction includes bed rest, mor-
phine and at times embolectomy. Removal

of bronchial obstruction is imperative in
cases of atelectasis. Aspiration of air from
the pleural cavity may be required in pneu-
mothorax. Treatment of pulmonary edema
consists in treatment of the cause. Arti-
ficial respiration is necessary in cases of
asphyxia.

19. The object of treatment in renal
emergencies is to restore urinary secretion.
Forcing fluids, limitation of salt intake,
aminophylline, diathermy, spinal anesthe-
sia, splanchnic block and kidney decapsula-
tion may be tried, in this order, to induce
diuresis. If acidosis is present, it must be
combatted by intravenous injection of Hart-
mann’s solution.

20. Diabetic coma requires insulin, in-
travenous infusion of saline, gastric lavage,
cleansing enemas, and in some cases intra-
venous glucose solution and blood trans-
fusions.

21. Hypoglycemic shock treatment con-
sists in administration of glucose by the
most convenient and practicable route.

22. Intravenous infusions of salt solu-
tion and administration of adrenal cortical
extract and DCA are usually very effective
in the management of Addisonian crises.

23. Ice packs and ice water enemas to
control hyperpyrexia, and inorganic iodides
to prevent liberation of the thyroid hor-
mone are the two important measures in
treatment of thyroid crises.

24. Calcium salts and parathormone are
required to restore blood calcium to its
normal level in cases of parathyroid tetany.

25. Epinephrine is the most useful and
effective drug in the management of all
forms of allergic emergencies. It may be
given subcutaneously, applied topically, or,
in extreme cases, injected intravenously.
Aminophylline, potassium iodide, oxygen-
helium inhalation, and intravenous fluids
supplement epinephrine in the management
of bronchial asthma. If the patient does
not respond to epinephrine, ephedrine sul-
fate may prove effective. Severe angioneu-
rotic edema may require tracheotomy or in-
tubation.

26. Gastrointestinal emergencies are
predominantly surgical problems, but pre-

Saunders — Common Medical Emergencies

551

operative medical treatment is important in
preparing the patient for operation. De-
compression of the bowel, restoration of
fluid and electrolyte balance, bed rest and
sedation are indicated in these cases.

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552

Wilson and Dunlap — Clinico-Pathologic Conference

CLINICO-PATHOLOGIC CONFERENCE

J. L. WILSON, M. D.f
ami

C. E. DUNLAP, M. D.ff
New Orleans

The following clinico-pathologic con-
ference presents some interesting diagnos-
tic problems. The history of the patient is
as follows :

M. P., a 22 year old colored female, was admitted
to the Charity Hospital on September 14, 1944 and
died on October 27, 1944.

Summary of History. The patient was admitted
with a chief complaint of hemoptysis, saying- she
had been perfectly well until three days previously
when she developed a slight cough, only slightly
productive and not troublesome. The night before
admission she had a severe coughing attack, rais-
ing about half a cupful of bright red blood. She
had been known to be a severe diabetic for about
six years. There had been no loss of weight, no
night sweats, and no fever noticed. Review of
systems was negative. Past and family history
normal, except for past history of diabetes. She
was married, and had two children, both well.

Summary of Physical Examination: Tempera-

tive 99.2°, pulse 88, respirations 26, blood pressure
120/80. She was well developed, well nourished,
and “did not appear to be acutely ill.” Head, E. E.
N. T. essentially normal. Lung fields were re-
sonant to percussion “breath sounds clear and
normal, no rales or other abnormalities.” The
heart rhythm was regular; no murmurs. The
abdomen was flat and relaxed, no tenderness, no
palpable organs or masses.

Summary of Laboratory Findings: October 4,

1944 white blood cells 15,800; October 17, 1944
white blood cells 13,000. Urine on admission acid,
1.018, alb. 0, sugar 4 + , acetone 3-f. Blood glu-
cose 276 on September 27, 1944 and 250 on October
2, 1944. COo 11 on September 27, 1944. Serology
negative. Neufeld negative on October 20, 1944.
Four smears for acid fast bacilli negative; five
concentrates for acid fast bacilli negative. EPA
chest on September 14 showed infiltration and fibro-
sis in the upper third of right lung; on September
26 EPA chest showed right pneumothorax, 40 per
cent collapse. Urinalysis for sugar and acetone
were done three times daily during hospitalization,
varying from negative to 4+ sugar and acetone
without regularity or consistency.

Summary of Previous Records: She was first

treated here as a clinic patient in 1935 for chronic-
ally diseased tonsils, again in 1938 for pain in

From the fDepartment of Medicine and
•(••{•Department of Pathology, School of Medicine,
Tulane University of Louisiana.

Fig. A. M. P. ; roentgenogram of chest on ad-
mission, September 14, 1944, showing infiltration
and contraction of right upper lobe.

lower right quadrant, “urinalysis negative”
thought due to cystic ovary, then sent to surgery
clinic in 1939 for “chronic appendicitis.” Seen
again in 1940 complaining of “pain in calves” and
loss of weight in spite of good appetite. Next
note is from postpartum clinic in May, 1941 say-
ing “she is a known diabetic since 1940, April.”
Returned in December 1941 as “possible preg-
nancy.” She had a five months’ miscarriage in
1941. Delivered a child on April 21, 1942 in the
hospital with no complications, being maintained
on 40 units of protamine zinc insulin daily. Re-
turned to delivery room on July 12, 1943 with BP
210/150 3+ edema; 4+ sugar and no albumin in
urine; delivered spontaneously and left the hospital
in good condition. On October 19, 1943 she was
admitted in diabetic acidosis following pain in
right side and chest, and vomiting for two days.
She was given sulfathiazole for “pyelonephritis”
and her acidosis and diabetes treated ; discharged
on 25 units of protamine zinc insulin. Blood sugar
had been 315 and CO„ 32 on admission.

Course in Hospital: The patient was in and out

of acidosis every day or so until after about two
weeks in the hospital, after which only traces of
acetone were found except for 2+ on October 22,
and October 26. The urine was never sugar free
for more than a few hours, in spite of large doses
of insulin. She was receiving 20 units of regular
insulin and 70 units of protamine zinc insulin
daily for the last few days of life. She had low

Wilson and Dunlap — Clinico-Pathologic Conference

553

grade fever until the end of September when the
fever increased to 105.4 on September 27, 1944
after which the curve was remittent; between nor-
mal and 105°. Her temperature fell to 97.2 at
4:00 a. m. on the day of death. The pulse rate rose
continuously and was over 140 for the week pre-
ceding death. Pneumothorax (right) had been

Fig. B. M. P., October 17, 1944, ten days before
death, showing infiltration of entire right lung
and central part of left lung. Note nasal catheter
for oxygen.

started on September 22, 1944 and was refilled
regularly, the last was 250 c. c. on the day of
death. For the last few days of life the diabetes
was very erratic and difficult to control. On Oc-
tober 23 consolidation of the right lower lobe was
found and coarse moist rales throughout the lung
fields. She became semi-comatose early on October
27, sugar 0, acetone 0 (urine). A dextrose infu-
sion was given, also adrenalin, coramine and 0„.
From 4:00 a. m. until death at 2:00 p. m. the
urine sohwed 1 to 2+ sugar but no acetone. She
expired in coma.

Dr. J. L. Wilson: The patient to be pre-
sented this morning is a 22-year-old colored
female and she has a rather short and
simple history. Her present illness began
only three days before admission with an
apparently acute infection and a slight
cough, only slightly productive. Suddenly
the night before admission she began

coughing up blood ; altogether about a half
cup of bright red blood. This happened in
a young negress known to be a diabetic
since 1940. She had no loss of weight, no
night sweats and no fever. A review of the
systems was negative.

Family and past history, if we disregard
diabetes and pregnancy, was negative. She
was married and had two children.

On admission physical examination
showed she was running a subfebrile tem-
perature of 99.2°; respirations were 26;
pulse 88; blood pressure 120/80. She was
well developed, well nourished, and not
acutely ill. The physical examination was
essentially negative; no abnormal findings
reported in the lungs.

Among the laboratory findings we are at
once struck by the urinalysis : specific grav-
ity 1.018, sugar 4 plus and acetone 3 plus.
Blood glucose first recorded thirteen days
after admission was 276. Carbon dioxide
was very low, only 11. The serologic test
for syphilis was negative. Sputum was neg-
ative for pneumococci, by Neufeld method.
Four sputum smears were negative for tu-
bercle bacilli. X-ray of chest on Septem-
ber 14 showed an infiltration, interpreted
as fibrosis in upper third of right lung.
The other laboratory findings follow in the
course of her illness.

She has a fairly extensive previous hos-
pital record, having been treated here for
diseased tonsils in 1935; in 1939 for pain in
the right lower quadrant, thought to be due
to cystic ovary or appendicitis. She was not
operated upon. It is noted at that time the
urine examination was negative. In April,
1940 she came in complaining of pain in
calves and loss of weight in spite of good
appetite. At that time it was discovered
she was a diabetic.

We find her obstetric history is also in-
teresting. In 1941 she had a miscarriage
at five months. Within a year of that date
she delivered a normal child, no complica-
tions, in April, 1942. At this time it is
noted she was maintained on 40 units of
protamine-zinc insulin daily. She was back
again in July, 1943 and was delivered of

554

Wilson and Dunlap — Clinico-Pathologic Conference

another normal child with spontaneous de-
livery. In October, 1943 she came in in
diabetic acidosis following an episode of
pain in the right side and chest. That is
not descriptive of exact localization of pain
and leaves doubt as to whether she had
pneumonia, whether tuberculosis produced
pleurisy or whether she had a recurrence
of her old abdominal pain. At any rate it
was discovered that her urine was full of
pus. She was treated with sulfathiazole,
cleared of pyuria, discharged, being main-
tained on 25 units of protamine-zinc insu-
lin. The blood sugar had been 315 on that
admission and carbon dioxide 32.

She then was followed in the out-patient
clinic but was not followed very closely.
There were traces of acetone in the urine
at times. The urine was never sugar-free
very long.

On admission to the hospital for the last
illness a great deal of difficulty apparently
was found in regulating her diabetes. On
September 15, the day after admission, a
note by the intern said “diabetes now under
control. Two days later, on September 17,
a note by the resident, underlined, stated
“diabetes not controlled.” She had a low
grade fever for the first week in the hos-
pital, when the fever increased to a maxi-
mum of 105° daily, after which the curve
was remittent between normal and 105°.
On the date of her death at 4 :00 a. m. her
temperature fell to 97.2°. Her pulse rate
rose continuously and was over 140 during
the last days of her life. She became semi-
comatose early on the last day of her life.
Sugar was absent, and acetone absent from
the urine. She was given dextrose infu-
sion, adrenalin, coramine and oxygen.
From 4:00 a. m. until death at 2:00 p. m.
the urine showed one to two plus sugar, no
acetone. She died in coma.

As far as treatment is concerned, she
came in with infiltration in the right lung,
the upper lobe, and it was our impression
that the upper lobe was greatly contracted.
Pneumothorax was instituted a few days
after admission. Twelve days later there
had already appeared an infiltration in the
left lung. With this extension of the pul-

monary disease the temperature jumped to
105°. By October 17, a month and three
days after admission, she was again critic-
ally ill with high temperature and increas-
ing shortness of breath and a chest x-ray
showed a complete infiltration of the right
lung and heavy infiltration of the middle
third of the left lung.

There can be very little discussion of the
diagnosis in this case. I think it is per-
fectly clear that this patient had proved
diabetes mellitus. The tuberculosis is not
proved in that she had nine sputum exami-
nations, all negative. A tuberculin test is
not mentioned. On the other hand, what
else could this be in a diabetic of 22 with
a history presenting this type of lesion with
rapid progress throughout both lungs ex-
cept pulmonary tuberculosis? It certainly
was not a pneumonia of the ordinary lobar
variety. No pneumococci were found. The
course of the disease, distribution, and
x-ray findings are all against pneumonia.
Some form of lung abscess or some form
of progressive disease due to actinomycosis
or other fungi is possible, but when one
guesses at such diagnoses he is flying in
the face of overwhelming probability. All
we lack in proof of a diagnosis of tubercu-
losis is the demonstration of tubercle ba-
cilli. With this type of tuberculosis — if
we assume it is tuberculosis — it is not at
all uncommon to have a negative sputum
since the process is one which invades the
lung rapidly producing consolidation with-
out time for cavitation to develop.

There are certain points in the history
to emphasize, presuming this is tubercu-
losis. First, the relation of diabetes and
tuberculosis. It has long been recognized
that diabetics are very much more prone
to develop pulmonary tuberculosis than
non-diabetics. Statistically they are two
or three times as liable to have tuberculo-
sis. It has also been noted that the de-
crease in mortality from tuberculosis is not
accompanied by decreasing incidence of
tuberculosis in diabetics. In pre-insulin
days the young diabetic particularly, did
not live long enough to develop tuberculo-
sis. In spite of the fact that 60 per cent of

Wilson and Dunlap — Clinico-Pathologic Conference

555

the diabetics we see now are in the middle
aged or elderly age group, the life of the
diabetic is prolonged sufficiently to die of
something else besides diabetes and nine
or ten per cent of deaths among diabetics
are caused by tuberculosis. The explana-
tion for this tendency to develop tubercu-
losis is purely hypothetical; probably not
directly related to hyperglycemia but to
other disturbances of metabolism, particu-
larly of fat metabolism with an increase
of glycerol in the system, since it is well
known that the tubercle bacillus thrives in
certain concentrations of glycerol. It may
also be due to deranged protein metabolism
or other factors ; not necessarily due to hy-
perglycemia. It has been recognized that
the patient with diabetes who is fairly well
regulated and never has ketosis does not
seem to be particularly prone to develop tu-
berculosis. Of those patients with ketosis,
a very considerable percentage develop
progressive tuberculosis within two or
three years after an attack of diabetic coma.

The other factor in this case that was
bad was that this woman had a miscar-
riage at five months ; she had then another
pregnancy and then within a year a third
pregnancy. On the third admission when
she had her second living child, she had an
elevated blood pressure, marked peripheral
edema and the record says “no albumin in
urine,” but the history shows that at times
with the first and second pregnancy she had
a good deal of albumin in the urine, so pos-
sibly she had a certain degree of toxemia
of pregnancy also. These repeated preg-
nancies, in my opinion, were contributory
to her down-hill course with pulmonary tu-
berculosis. I do not think one can escape
the fact that the strain of pregnancy, de-
livery and care of small children after de-
livery contributed to the progression of her
disease.

Another point brought out by this case is
the question as to why her diabetes was so
difficult to control. Outside of the hospital
it is obvious that the diabetes was difficult
to control because we were dealing with an
ignorant patient, making occasional visits
to the clinic and unable to master details

essential for its control. In the hospital in
this last illness it seems to me that her
diabetes was unusually difficult to control.
On the ward we stepped up her insulin
every few days in an effort to get the urine
free of acetone and then sugar and although
the dosage mounted to a total of 90 units of
insulin she was still putting out sugar and
occasionally acetone in the urine. In a
lesser degree this is rather characteristic
of every case of tuberculosis and diabetes.
Often patients admitted with acute, active
pulmonary tuberculosis, particularly when
febrile, take large dose of insulin for con-
trol. Later as the tuberculosis comes under
control and the temperature becomes nor-
mal on rest therapy, the dose of insulin re-
quired becomes smaller and smaller. Oc-
casionally we see a patient get along with-
out insulin after the tuberculosis has been
successfully treated.

In summary, we have a young woman, a
negress, who has had three pregnancies in
rapid succession; who is a known diabetic
with moderately severe diabetes becoming,
under the impact of infection, rather
markedly severe, with no previous x-rays,
but evidence by x-ray on admission of a
minimal, contracted tuberculosis of the
right apex. Within a short time, after un-
successful pneumothorax, tuberculosis
spreads throughout that lung and to the
other side. The diabetes becomes more
and more difficult to control. The patient
becomes increasingly dyspneic and ex-
pires within six weeks of the time of ad-
mission. The clinical diagnosis — diabetes
mellitus and pulmonary tuberculosis.

Dr. C. E. Dunlap : Dr. Wilson, do you be-
lieve the character and course of tubercu-
losis in the diabetic differs from tubercu-
losis in the non-diabetic?

Dr. Wilson : One has to define the

terms. When cases of diabetes and tuber-
culosis are assembled we find many in the
elderly diabetics with a fibrous form of tu-
berculosis, but as one goes down the age
scale to the younger diabetics, I think it is
definite that the diabetic who is uncon-
trolled has a florid type of tuberculosis,
very frequently appearing in the lower part

556

Wilson and Dunlap — Clinico-Pathologic Conference

of the lung and extending rapidly through-
out the lung.

Dr. Dunlap : Dr. Musser, do you care to
say anything about the patient?

Dr. J. H. Musser : There are two or three
things which are rather interesting. Aside
from the immediate cause of death, I was
interested in these distinct evidences of
toxemia of pregnancy and I wondered if, in
addition to the tuberculosis, you are not
going to find the kidneys rather badly
damaged.

Another thing I think is quite remark-
able is the notation that fever was of a low
grade until suddenly on the twentieth day
of September the fever suddenly jumped to
105° and thereafter was remittent between
that figure and the normal figure. I be-
lieve she developed a blood stream infec-
tion at this time, so she had not only tu-
berculosis of the lung but also disseminated
throughout the body.

The third thing that I would like to com-
ment on is the fact that every once in a
while we are very fortunate in having a
person with tuberculosis who has a con-
comitant diabetes and when that occurs in
these fortunate cases, as I say, the tuber-
culosis will disappear almost as rapidly as
the diabetes is being controlled by insulin.
It is really very spectacular but unfor-
tunately it only happens occasionally. The
first patient I treated with tuberculosis,
who had diabetes, was a man about 43 and
at that time insulin had just been intro-
duced. He was coughing up a large num-
ber of tubercle bacilli every day, lost
weight rapidly, and his progress was very
markedly downhill. He was put on insulin.
The improvement was spectacular. He
went ahead and took care of his tubercu-
lous process and we took care of his dia-
betes. The last time I saw him, six or seven
years after, he was just as well and
strong and healthy as a man could be with
a well controlled diabetes.

One other point I would like to bring out
that Dr. Wilson mentioned, namely, that
this patient was well treated, I think, about
as satisfactorily as any one could be treated.
I would like you to remember that coma is

not necessarily coma that is due to a ke-
tosis. This patient had been receiving large
doses of insulin and it is quite possible that
the coma that she went into before she ex-
pired might have been a hypoglycemic re-
action. Therefore I would like to stress the
importance always of examining the urine
of a patient to whom you are going to give
insulin if you are not thoroughly acquaint-
ed with the case. I think that is almost ob-
ligatory because we have known of patients
who have gone into a real coma and been
given further doses of insulin when the
coma was actually hypoglycemia produced
by overdosage of insulin.

Dr. Dunlap: Are there any other com-

ments or questions? (No one responded.)

Dr. Edenfield will you enter the students
diagnoses on the board? (These were as
follows) :

Pulmonary tuberculosis — 15
Miliary tuberculosis — 3
Lung abscess — 1
Pulmonary infarction — 3
Diabetic coma — 2
Bronchopneumonia — 5
Diabetes — 10
Insulin shock — 3

Dr. Edenfield : There were various com-
binations of diagnoses, that is, all those who
listed diabetes also gave additional diag-
noses.

Dr. Dunlap : Students are conservative

diagnosticians. Dr. Wilson, as we have
learned to expect, has made the correct
diagnosis. Nevertheless this is a very in-
teresting case from the teaching point of
view and we thought it well worth present-
ing.

Dr. Wilson has correctly diagnosed the
collapse of the right upper lobe and the ex-
tensive tuberculous involvement of the re-
maining lobes. The right upper lobe was
adherent to the chest wall at the apex by
fibrous adhesions. The lobe was unexpand-
ed and on section showed extensive casea-
tion and fibrosis. The disease had appar-
ently extended from this region into the
entire right lung. Throughout the lung
there are yellow nodular masses of caseous
material with consolidation of the inter-

Wilson and Dunlap — Clinico-Pathologic Conference

557

vening lung tissue. A very similar pic-
ture is present throughout the left lung. In
fact here the nodules of tuberculosis are
even less discreet and become confluent
throughout practically all of the lung tissue
with the exception of a few marginal re-
gions. Apart from these two lungs and the
hilar lymph nodes we did not find any gross
evidence of tuberculosis in other parts of
the body.

The spleen appeared normal in the gross
as well as on microscopic examination.
We rather expected to find some disease
of the kidneys but this was not found. The
kidneys were normal both grossly and mi-
croscopically. The small size of the heart
suggests that this patient did not have a
long, continued, or permanent hyperten-
sion. It is therefore probable that her hy-
pertension during a previous pregnancy
was not long continued, since cardiac hyper-
trophy is practically a constant accompani-
ment of sustained hypertension. The liver
had a somewhat smooth, glossy, watery
appearance. It did not contain excessive
quantities of fat.

As far as the diabetes is concerned, we
found nothing at autopsy which would jus-
tify a positive diagnosis of diabetes and
we have no apologies to offer for that. The
pancreas weighed fifty-five grams and
microscopically the islets appeared normal.
This is what we find in as many as half
the cases of diabetes. It seems rather in-
congruous perhaps that a disease as defi-
nite and as dramatic as diabetes should not
be associated with consistent and recog-
nizable pathologic changes. In those cases
in which the pancreas is destroyed, of
course one finds clinical diabetes. In other
instances we may find changes in the is-
lands ranging from rather subtle changes,
such as hydropic degeneration to extensive
fibrosis or hyalinization of the islands. In
these instances it seems reasonable to at-
tribute the diabetes to insular damage but
in other cases as I mentioned previously,
the islets are anatomically normal. This
naturally leads one to wonder whether
all cases of diabetes are primary diseases
of the pancreas or whether some may not

represent dysfunction of. other organs, pos-
sibly the pituitary.

I think, before discussing this case any
further, we might show three lantern
slides illustrating the lesions of tubercu-
losis as they occurred in the lungs and also
one slide of the liver.

You probably recall that a few weeks ago
we presented here a case of first infection
tuberculosis showing a fairly well localized
lesion of the lung surrounded by lympho-
cytes and fibroblasts, without any patho-
logic changes in the neighboring lung tis-
sue. Here we see a very different picture
in the lungs. The tubercle present in the
center of the slide is without definite,
clearly demarcated margins. There is no
evidence of attempted walling-off or
lymphocytic accumulation. About this le-
sion we find extensive changes in the neigh-
boring lung including edema, infiltration
of many macrophages and also many poly-
morphonuclear leukocytes. This picture
was present throughout the entire lung. In
many regions there were extensive areas of
confluent caseation, and the whole picture
was, as Dr. Wilson predicted, one of tuber-
culous pneumonia. This reaction around
obvious centers of tuberculosis is frequently
attributed to an allergic inflammation and
there is some argument as to whether tu-
bercle bacilli themselves extend to the
limits of the inflammatory process. Clinic-
ally patients with tuberculous pneumonia
may show a considerable amount of reso-
lution of that portion of the lung which
was previously consolidated, and we pre-
sume that resolution takes place in the re-
gions of non-caseating inflammation and
not in regions which are frankly caseated
with destruction of lung tissue. Therefore
the extent of consolidation in tuberculosis,
as seen by x-ray, does not represent the ex-
tent of irreversible disease and consider-
able resolution and clearing may take place.

The next slide shows the only extra-
pulmonary lesion of tuberculosis which we
were able to find in this patient. This is in
a lymph node at the hilus of the lung and
we see a nice early tubercle with two big

558

Wilson and Dunlap — Clinico-Pathologic Conference

giant cells surrounded by a border of epi-
thelioid cells and lymphocytes.

We found no tuberculosis in the gastro-
intestinal tract where it is not uncommon
to find rather recent tuberculous ulcera-
tions in patients who have brought up in-
fected sputum and swallowed it. We in-
terpret many intestinal lesions as having
occurred shortly before death and record
them as incidental findings. In this case
we found no such lesions.

The next and last slide, is one of the liver
taken at high magnification. I mentioned
that, without the clinical history, we would
not have been able to make the diagnosis of
diabetes. There are, however, a few patho-
logic findings frequently present in uncon-
trolled diabetics and among these is glyco-
gen in the liver cell nuclei. Glycogen is
normally present in the cytoplasm of he-
patic cells but in a diabetic it may be de-
posited in the nuclei, pushing the chroma-
tin to the periphery and leaving a pale
empty looking central area. We sometimes
find a similar change in patients who re-
ceive large quantities of intravenous glu-
cose shortly before death so we cannot con-
sider this or other disturbances of glycogen
deposition as absolutely pathognomonic of
diabetes. Another change observable in
this slide is edema of the liver, a diagnosis
that for some reason is seldom made and
probably a change that interferes little if
at all with the function of the liver. Since
the liver contains such a small amount of
connective tissue, accumulation of fluids in
the liver must seek a different site and is
ordinarily found between the endothelium
of the sinusoid and the adjacent liver cells.
Here is the endothelium of a sinusoid of
the liver which is normally approximated
to the adjacent cells but here it is separated
from the liver cords by a clear space pre-
sumably representing edema fluid. We
find this change quite frequently in well
hydrated or excessively hydrated patients
who come to autopsy and believe it has
little importance as far as liver function is
concerned.

I would like to return for a moment to
a point already discussed ; two points for

that matter; first, the pregnant diabetic
and second, the diabetic with infection.
Well controlled diabetes apparently does
not interfere greatly with conception or
gestation and constitutes a relatively minor
hazard to the parturient woman. However
the children of diabetics frequently fail to
survive. Hellwig has examined the pan-
creases of babies born of diabetic mothers
and has found considerable increase in the
total volume of islet tissue. It has been
proposed that the baby of a diabetic mother
developing in an environment poor in in-
sulin, compensates by a functional hyper-
plasia of its own islet tissue, and may suf-
fer from severe postnatal hypoglycemia.
In recent years babies born of diabetic
mothers have had a much better chance of
survival and this in part is due to intelli-
gent care of the baby. The blood sugar is
determined and a fall level that is danger-
ous to life is combatted by supplying sugar
to the baby.

As far as infection in diabetes is con-
cerned, there is little evidence that a well
controlled diabetic is more subject to infec-
tion than a normal person. The difficulty
with such a statement is that few diabetics
are perfectly controlled at all times and
that once a diabetic does acquire an infec-
tion it becomes increasingly difficult to
control the diabetes.

Dr. Wilson mentioned the factor of in-
creased blood and tissue sugar which has
been used by some to explain the increased
incidence of infection in diabetics. It has
been pointed out by bacteriologists that a
sugar concentration greater than 0.1 per
cent or 100 mg. per cent in artificial cul-
ture media does not favor the growth of
any of the ordinary pathogenic bacteria and
hence the increase of blood or tissue sugar
above this level would not be expected to
favor growth of micro-organisms in tissue.
We have no explanation of increased sus-
ceptibility of diabetics to infection. It is
amazing to consider how little we really
know about diabetes, as to its etiology, its
essential nature and its complications. The
great success of the modern treatment of
diabetes is a fine tribute to empirical

Wilson and Dunlap — Clinico-Pathologic Conference

559

medicine based on sound but incomplete
scientific data.

I think that is all I have to say. Dr.
Wilson, do you care to make any further
remarks ?

Dr. Wilson: In trying to read back and
interpret the course of events, Dr. Dunlap,
in the right upper lobe — was that a re-
cent process or old process and did the
bronchus show obstruction to produce
marked diminution in size of the right up-
ber lobe, or was this due to the fibrosis of
a long-standing process? Also, was there
any ulceration into the bronchus?

Dr. Dunlap: There was no calcification

and no old brawny fibrosis in the right up-
per lobe although fibrous tissue was more
abundant there than elsewhere and an en-
capsulated region of caseation was present.
I believe this represents the original site of
infection. We found no ulceration of the
bronchi or any ulceration into the lymph
nodes.

Dr. Wilson: In children and in negroes

of older age than children, ulceration into
the bronchial tree is not uncommon and can
present the picture of tuberculous pneu-

monia. I think we must assume in this
case that the diabetes probably existed
longer than the known period but also that
she probably had pulmonary tuberculosis of
the right upper lobe for many months, as
it must have taken time for the right upper
lobe to shrink to that degree. And then un-
der the stimulus of uncontrolled diabetes,
she developed rapidly progressive tubercu-
losis. Pneumonia was widespread and even
in the last 24 hours of life she must have
developed a great deal of this collateral
inflammation or reaction in the paren-
chyma of the lung to tuberculosis without
definite caseation. On October 17, ten days
before exitus, she still had a considerable
portion of the left lung areated and yet by
deduction from the nasal catheter in the
x-ray she was under oxygen at that time.

Student: Dr. Wilson, might not the in-

stitution of pneumothorax be of danger in
disseminating the tuberculosis from one
lung to the other?

Dr. Wilson : The pneumothorax was in-
stituted as an emergency to control hemop-
tysis. With negative sputum there is no in-
creased danger of collapse causing a spread
to the other lung.

560

Editorials

NEW ORLEANS

Medical and Surgical Journal

Established 18 UU

Published by the Louisiana State Medical Society
under the jurisdiction of the following named
Journal Committee:

Val H. Fuchs, M. D., Ex officio
For two years: G. C. Anderson, M. D., Chairman
Leon J. Menville, M. D.

For one year: J. K. Howies, M. D., Vice-Chairman
For three years: C. Grenes Cole, M. D., Secretary
E. L. Leckert, M. D.

EDITORIAL STAFF

John H. Musser, M. D Editor-in-Chief

Willard R. Wirth, M. D Editor

Max M. Green, M. D Associate Editor

COLLABORATORS— COUNCILORS
Edwin L. Zander, M. D.

J. T. O’Ferrall, M. D.

Guy R. Jones, M. D.

T. B. Tooke, Sr., M. D.

George Wright, M. D.

W. E. Barker, Jr., M. D.

C. A. Martin, M. D.

W. F. Couvillion, M. D.

Paul T. Talbot, M. D General Manager

1430 Tulane Avenue

SUBSCRIPTION TERMS: $3.00 per year in ad-
vance, postage paid, for the United States; $3.50
per year for all foreign countries belonging to the
Postal Union.

News material for publication should be received
not later than the eighteenth of the month preced-
ing publication. Orders for reprints must be sent
in duplicate when returning galley proof.

Manuscripts should be addressed to the Editor-
in-Chief, 1$30 Tulane Ave., New Orleans, La.

The Journal does not hold itself responsible for
statements made by any contributor.

ETHICAL ADVERTISING?

It is most discouraging, disheartening
and in a sense disgusting to read some of
the advertising which is now appearing in
the New Orleans newspapers. The adver-
tising referred to has to do with patent
medicines. There was a period of time
when practically every ethical newspaper
in this country refused to accept certain
types of proprietary medical advertise-
ments. They seem to have come back with
a rush recently.

It is assumed that an advertisement gives
endorsement to a product or at least as-
sumes that a product or preparation is
honest yet when the supposed symptoms
of a nephritis are presented in an adver-
tisement and then the reader is told to take
a certain preparation for his kidneys which
at the best will do no good and may actually
be harmful, then the newspaper is not
dealing fairly with the public. If the in-
dividual has kidney disease definitely that
person should be under the care of a doc-
tor. Kidney disease is not diagnosed by
the presence of backache or pain in the legs
and the remedy suggested cannot possibly
be of benefit to the sufferer from nephritis.
One of the New Orleans evening papers
has an advertisement of the famous ( ?)
Lydia Pinkham’s vegetable compound. The
ineffectiveness of this preparation has been
repeatedly exposed. In the same number
of the evening paper in which this adver-
tisement appears there are advertisements
for remedies that will cure eczema, ring-
worm, scabies on one application. There
are innumerable advertisements having to
do with deodorants, cures for sour stomach,
cures for athlete’s foot, cures for head-
aches, all sprinkled through the advertis-
ing columns. A two column wide adver-
tisement recites how a special vitamin pre-
paration of secret formula “peps up” an
individual who feels “dull or is slowed
down.” Vitamins do not and cannot have
this effect.

The New Orleans morning and evening
paper under the same management is filled
with these distinctly unethical advertise-
ments. It can be said to the credit of the
other evening paper that it has not de-
scended to kidney pills and dysmenorrhea
cures but it does advertise innumerable de-
odorants, none of which are probably of any
value whatsoever.

o

HOUSE BILL 1391

The medical profession should support
the bill introduced by Dr. A. L. Miller
of the fourth district of Nebraska which
provides for a secretary of Cabinet rank

Editorials

561

in a proposed Department of National
Health. This, if passed, will accomplish
that which has been advocated for many
years by the medical profession. Repeat-
edly the House of Delegates of the Ameri-
can Medical Association has passed resolu-
tions to the effect that there should be an
executive department under which should
come all the various medical activities of
the United States Government and at whose
head should be a Secretary of National
Health.

Dr. Miller states that there are thirty-two
Federal agencies dealing with various
phases of health. These agencies are scat-
tered throughout the Government. The
United States Public Health Service, for
example, a very large organization, has
been under the Treasury Department, al-
though recently placed under Federal Se-
curity Agency. Certain hospitals are un-
der other agencies or departments. The De-
partment of Agriculture has moved far in
advancing socialistic medicine through
some of its divisions. The Department of
the Interior has charge of one of the most
important Washington hospitals and other
hospitals scattered throughout the country.
One could continue almost indefinitely re-
citing the departments and agencies that
deal with matters medical. It is only the
part of good common sense to amalgamate
the various medical agencies under one
head who, of course, should be a physician
who should outline the policies of the health
services given by the United States Gov-
ernment and who should have the rank of a
cabinet officer.

o

THE WRITING OF PRESCRIPTIONS

It might be wise to call attention to the
text of the resolutions adopted by the House
of Delegates of the Louisiana Medical So-
ciety at the annual meeting held in 1944,
which were sent to the chairman of the
Committee on Medical Education. These
resolutions are printed elsewhere' in the
Journal. The resolutions are critical of
the lack of knowledge of dosage of drugs
and preparation of prescriptions by recent
graduates. It is somewhat difficult to

know why students who have just gradu-
ated do not know the dosage of import-
ant drugs. They certainly had the oppor-
tunity of seeing and hearing about the
treatment of the sick patient and the dis-
cussion of the treatment includes the dos-
age of the drug. On the other hand it is a
well known fact that the younger physicians
do not write prescriptions which would
give the pharmacist exact directions as
how to prepare the combination of drugs
contained in a prescription. This is prob-
ably dependent upon several factors, one of
which lies in the fact that prescription
writing is reduced to almost the irreducible
minimum during the term of service of a
neophyte in medicine as an intern. It is
customary to write hospital orders with a
single drug being given at a time or if three
or four drugs are given they are ordered as
single preparations and not combined with
one another. The consequence is that what
prescription writing a man has learned as
a student is forgotten when his internship
is completed. Another factor which plays
a role in the deterioration of the art of pre-
scription writing is that there is a tendency
in practice today, as is done in hospitals, to
write a prescription for one drug alone and
not to confuse the issue by a combination of
two or more drugs. This is probably an
excellent method of prescribing. Rarely
nowadays is digitalis given in combination
with other drugs. It is much better to give
belladonna by itself and to work up to the
physiologic limit of dosage. The sulfa pre-
parations are given in tablet form which
contains only this one drug. Many other
drugs could be enumerated from which the
physician expects a definite reaction.

One of the past masters of therapeutics
has said, “know a few drugs and know them
completely.” This is a wise dictum and
well could be followed by medical prac-
titioners. However, this does not mitigate
the importance of knowing the important
drugs and their dosage and how to prepare
them when and if they are put in combina-
tions which should have the dosage of the
several drugs proportioned properly to the
need of a specific patient.

562

Organization Section

THE TREATMENT OF ESSENTIAL
HYPERTENSION

The present day treatment of hyperten-
sion should be directed towards treatment
of the underlying pathology, whatever that
may be, and the treatment of the symptoms.
Ayman* writes that the three dominating
groups of symptoms in this condition are:
(1) psychosomatic, (2) vasospastic, and
(3) organic. With the first there occur
headaches, weakness, inability to sleep, fre-
quency of urination, dizziness and altera-
tion in bowel habits. The vasospastic symp-
toms are indicative of more advanced vas-
cular change and include headaches, at
times convulsions and occasionally tem-
porary paresis. In the third group, the
symptoms arise as result of either cardiac
or renal damage or vascular disease of the
brain. To the first group of patients seda-
tives are largely employed. For the other
group of patients symptomatic therapy is
indicated ; digitalis, for example, for the in-
dividual with the large heart in partial
failure.

Recently potassium thiocyanate has en-
joyed a rejuvenation. Some years ago, in

*Ayman, David : Present day treatment of es-
sential hypertension, Quart. Rev. Med., 2:190,
1945.

the treatment of hypertension, its indis-
crimate use and its administration to im-
properly selected patients led to certain
eatastrophies which aroused a fear in the
use of this preparation. Now it is known
that potassium thiocyanate is a thoroughly
safe medicament when given at the onset of
treatment in doses of 0.2 gram three times
daily and then reduced to twice a day after
the larger doses have been given for three
or four days. It is wise in ordering this
drug to have the facilities for determining
the blood cyanate level. This level should
be maintained between 8-10 mg. per cent.
Toxic symptoms do not occur until the blood
levels are above 10-12 mg. per cent. If the
patient’s blood level can be ascertained and
if the patient can be kept on an adequate
maintenance dose there will result a lower-
ing of the blood pressure and with it a con-
comitant diminution in the patient’s symp-
toms. Other than potassium cyanate there
is really no effective drug in lowering blood
pressure. Sympathectomy has been dis-
cussed in these editorial columns and repre-
sents a method which may prove to be of
value to the person suffering from a hyper-
tension which is not only causing symp-
toms but which may terminate prematurely
the life of the individual.

o

ORGANIZATION SECTION

The Executive Committee dedicates this page to the members of the Louisiana
State Medical Society, feeling that a proper discussion of salient issues will contri-
bute to the understanding and fortification of our Society.

An informed profession should be a wise one.

REVEILLE FOR MEDICINE

Do you know that the Federal Government
failed to get out of committee the famous
Wagner Bill (S. 1161) ir. the 78th Con-
gress? However, they have not given up
their efforts and right now astute and able
politicians are still planning for the regi-
mentation of medicine. Following an old
political trick, seeing their inability to
succeed with the Wagner bill, they are now
most assuredly planning to break its dif-
ferent provisions into strong and far-reach-
ing bills, introduced under different nomen-

clature. Let us look at the record to prove
these assertions.

A. Recently Representative DingeJl,
from Michigan, introduced H. B. 395 which
is a duplicate of the original Wagner bill
with the exception of providing for the
individual selection of physicians and some
other minor changes. Thus, they still have
hope of being successful in these broad so-
cial security regulations covering benefits
from the cradle to the grave.

B. Recently as a result of a study made
by the subcommittee of the Committee on

Organization Section

563

Education and Labor, there has been intro-
duced Senate Bill 191 known as the Hill-
Burton bill, appropriating five hundred
million dollars for a survey over the United
States to ascertain the needs of hospitals.
It also provides, upon request, for the con-
struction and establishment of hospitals,
clinics and laboratories in states where such
facilities are shown to be needed.

C. H. R. 2550, known as the neuro-
psychiatric unit bill, provides for the estab-
lishment in Bethesda of a national psychia-
tric unit for the training of specialists and
treatment of mental diseases. It also pro-
vides for the establishment of mental hos-
pitals in the various states on state levels —
same to be approved by the Surgeon Gen-
eral of the United States Public Health
Service.

D. We have recently reviewed, with a
great deal of interest, the great expansion
of the Children’s Bureau in the medical
field. They are not satisfied with the ad-
vance on medicine recently made- by the
EMIC plan but are planning to enlarge
their handling of our problems.

Most of these bills and activities are dis-
guised under the exigencies of war and as
an aid for returning veterans. (Let us not
be deceived or lulled, by patriotism, into a
sense of security.) Their experts work
while we are sleeping or trying to keep up
with the heavy duties incident to the de-
pletion of medical men for civilian prac-
tice. All of these provisions, except in the
Children’s Bureau, are to be supervised,
controlled, dominated and enforced by the
Surgeon General of the United States Pub-
lic Health Service, just as these features
were provided for in the original Senate
Bill 1161, the Wagner bill.

May I direct your attention to a few
weaknesses in their policy so far estab-
lished? Have they not really forgotten the
basic A B C’s of good health which are so
basically an essential factor in maintain-
ing in our youths a healthy and robust
body? Why is it that they are so intent on
taking over the, practice of medicine when
they have failed so ignominiously and out-
standingly in their obligations to the people

in this basic essential hygienic factor? I
have reference to the neglect of our citizens
in regard to good homes, good food, good
personal hygiene, good community hygiene,,
freedom of polution of streams and relief
from infestation by insects, such as flies,
mosquitoes, etc., which we know to be a
basic factor in the dissemination of dis-
eases, particularly those occurring in the
early ages of childhood. If they, by ill fate,
are given the opportunity to take over the
practice of medicine, we have a real, prac-
tical outstanding example of what to antici-
pate from such a bureaucratic form of su-
pervision. Recently we have all been read-
ing in the lay press and special periodicals
severe criticism of the Veterans Adminis-
tration for their dismal failure and neglect
in not supplying adequate medical care and
proper hospital service to our veterans'.
What an indictment, if true, against a truly
federalized agency — a reflection of what tb
expect of over-all control of medicine by
Washington. This has proved a great
shock to proponents of federalized medi-
cine. They are scattering hither and yon
to cover up and counteract the damage
to their prestige which may prove to be a
tempest in a teapot.

This surely is not an acute condition. The
bureau has been in operation for over
twenty-five long years. It should have
reached its height of perfection and useful-
ness. Their hospitals have fallen far short
in mortality and morbidity rates of certain
diseases ; for example, tuberculosis and
mental cases, in comparison with great
progress made by private or state-owned
institutions. In view of this evidence, can
we be blind to the implications of political
regimentation of the great profession of
medicine and what it will mean to the pub-
lic at large and to the disintegration of
adequate medical services? Likewise, we
have witnessed the great dissatisfaction
with the EMIC plan emanating from the
Children’s Bureau; the failure of the ve-
nereal disease program; the reflection on
the infantile paralysis program, all of
which, except the EMIC, have been abso-
lutely under Government control. It means

564

Orleans Parish Medical Society

that in their blindness for the control of
medicine they think they see the mote in the
eyes of medicine but fail to see the great
big one in their own eyes. This must have
been so large and devastating as not only
to produce blindness but a total loss of sen-
sations and judgment in their failure to
provide an adequate preventive medicine
program. You hardly ever hear of the great
accomplishments of preventive medicine.
Formerly, we were taught that if pre-
ventive medicine was properly admin-
istered there would be very little need for
doctors. Diseases of man would be ex-
terminated. But this would mean lots of
work and a small political kick-back —
hence no interest for Uncle Sam.

In our recent selective service statistics,
the medical profession is accused of having
failed in their responsibility because four
million draftees were rejected for physical
unfitness, as far as fighting was concerned.
The whole responsibility is placed in the lap
of the medical profession. Let us analyze
these false statements. Do you know that
this country is now enjoying the greatest
era of prosperity and health ever enjoyed
by any nation? In spite of government
neglect of basic factors of good health and
gross neglect in the application of the basic
A B C’s of hygiene and sanitation, which
after proper application would have given
us an energetic and healthy stock, the
record of the medical profession and our
mortality and morbidity rates have reached

an all time low. May I ask, what would
have been accomplished if the Government
had performed its duty in the application
of the A B C’s of hygiene and sanitation?

You should know that the Congressional
Committee recently appointed by the Ex-
ecutive Committee of the Louisiana State
Medical Society is giving serious thought
and study to the above problems. They are
interested especially in a new federaliza-
tion bill S. 395. They also have apprehen-
sions that there may be introduced by Sena-
tors Wagner and Murray, in cooperation
with Representative Dingell, an entirely
new bill for federalization of medicine mak-
ing provisions for all of the above activi-
ties under one heading. From recent
Associated Press reports it was stated that
President Truman would support such a
measure. This committee very shortly
will reach some definite conclusions as to
the attitude of the State Medical Society in
relation to these problems. You may rest
assured that they are endeavoring to map
out some policy which will be most effective
in counteracting these nefarious bills pro-
posing to federalize or disorganize the
present American way of practicing medi-
cine.

Late information from the American
Medical Association states that Senator
Wagner introduced his new social security
bill on Thursday, May 24.

TRANSACTIONS OF ORLEANS PARISH MEDICAL SOCIETY

CALENDAR OF MEETINGS

June 4.
June 5.
June 6.

June 7.

June 11.

Board of Directors, Orleans Parish
Medical Society, 8 p. m.

Eye, Ear, Nose and Throat Staff, 8
p. m.

Clinico-pathologic Conference, Marine
Hospital, 7 :30 p. m.

Mercy Hospital Staff, 8 p. m.

Clinico-pathologic Conference, Touro In-
firmary, 12 noon.

Executive Committee, Baptist Hospital,
8 p. m.

Scientific meeting, Orleans Parish Med-
ical Society, 8 p. m.

June 13.

June 15.
June 18.
June 19.
June 20.

June 21.

June 22.
June 25.

Touro Infirmary Staff, 8 p. m.

Woman’s Auxiliary, Orleans Parish
Medical Society, Orleans Club, 3 p. m.
I. C. R. R. Hospital Staff, 12:30 p. m.
Hotel Dieu Staff, 8 p. m.

Charity Hospital Medical Staff, 8 p. m.
Clinico-pathologic Conference, Marine
Hospital, 7:30 p. m.

Charity Hospital Surgical Staff, 8 p. m.
Clinico-pathologic Conference, Touro In-
firmary, 12 noon.

L. S. U. Faculty, 8 p. m.

Board of Directors, Orleans Parish
Medical Society, 8 p. m.

Orleans Parish Medical Society

565

June 26. Baptist Hospital Staff, 8 p. m.

June 27. French Hospital Staff, 8 p. m.

June 28. DePaul Sanitarium Staff, 8 p. m.

June 29. New Orleans Hospital Dispensary for
Women and Children Staff, 8 p. m.

The May scientific meeting of the Society was
presented by members of the Charity Hospital
Staff. Drs. Manuel Garcia and J. Y. Schlosser
read a paper on The Treatment for Carcinoma of
the Cervix at Charity Hospital — Analysis of 716
Patients — Three- Year and Five-Year End Results;
discussion of this paper was opened by Drs. H.
W. Kostmayer, Charles Dunlap and Rudolph
Matas; Dr. John Adriani spoke on Some Hazards
of Anesthesia; An Interesting Obstetrical Case
Report was presented by Dr. Claude Callender;
and Dr. J. A. Rickies spoke on Multiple Common
Duct Stones — Case Report of Patient with Twenty-
six Common Duct Stones.

The next scientific meeting of the Society will
be held Monday, June 11; the program will be
presented by members of the Faculty of the L. S.
U. Medical School.

o

NEWS ITEMS

Drs. Oscar Bethea and C. L. Brown were re-
cently elected to the Board of Directors of the
Rotary Club of New Orleans.

Drs. 0. P. Daly and Lewis E. Jarrett were
elected to the Board of Trustees of the Louisiana
Hospital Association at a recent meeting of that
organization.

Dr. Joseph A. Danna was appointed by Mayor
Maestri to replace James Brodtman on the New
Orleans Housing Authority.

Drs. Joseph A. Danna, Val Fuchs, and C. Walter
Mattingly were re-elected directors of the New
Orleans Chapter of the American Red Cross.

Dr. Louis J. Dubos has been appointed pre-
employment medical examiner and consultant in-
ternist for the Southern District of the Texas Oil
Company.

Congratulations to Dr. and Mrs. M. J. Duffy,
who have a new son.

Drs. Thomas Findley, M. L. Michel and J. D.
Rives held a wartime postgraduate meeting (re-
gional staff of Camp Plauche and Camp Claiborne)
at Camp Polk at Leesville, April 9. Dr. Findley
gave two papers: (1) Surgical Treatment of Hy-
pertension; (2) Treatment of Thyrotoxicosis. Dr.
Michel presented a paper on Intestinal Obstruc-
tion, and gave a dry clinic on Vascular Diseases
of the Extremities. Dr. Rives gave a dry clinic

on Gallbladder Diseases, Thyroid Diseases, and
Carcinoma of the Colon.

Dr. Grace Goldsmith was recently elected presi-
dent of the Stars and Bars Chapter of Alpha
Omega Alpha; Dr. E. Z. Browne was re-elected
secretary-treasurer.

Dr. Jeanne Roeling-Hanley was elected second
vice-president, and Dr. Ada Schwing Kiblinger
member of the Board of Directors of the New
Orleans Quota Club at a meeting of that organi-
zation held April 21.

Dr. Thomas S. Kavanagh was recently esteemed
lecturing knight of the New Orleans Lodge of
Elks.

Dr. Waldemar R. Metz was guest speaker at the
meeting of the New Orleans Dental Association
which was recently held at the Marine Hospital.
Dr. Metz spoke on, “Harelip and Cleft Palate Sur-
gery and Its Relation to Dentistry.”

Dr. H. R. Unsworth has been appointed attend-
ing specialist in neuropsychiatry at the United
States Marine Hospital in Carville.

Dr. Julius Lane Wilson was re-elected president
of the Louisiana Tuberculosis Association at the
annual meeting of that organization held at the
Jung hotel April 17. Other officers elected were:
Drs. Chester A. Stewart and Sydney Jacobs, vice-
presidents; Drs. R. Alec Brown, Maurice Cam-
pagna, 0. P. Daly, Joseph A. Danna, Edgar Hull,
John H. Musser, I. L. Robbins and John M. Whit-
ney to the executive committee.

Drs. Ralph Platou and Edwin L. Zander were
elected to the Board of Directors of the Social
Hygiene Association of New Orleans at an annual
meeting of that organization, April 24.

Dr. George W. McCoy attended a meeting of the
District of Columbia Basic Science Examining
Board, in Washington, April 27.

Dr. Charles A. Bahn attended a conference
devoted to problems of industrial ophthalmology
sponsored by Columbia University College of Phy-
sicians and Surgeons in co-operation with the
Society for the Prevention of Blindness. The con-
ference was held at Columbia University Medical
Center, New York, May 7-11.

Congratulations and best wishes to Dr. John B.
Plauche, who was recently married.

DR. BETHEA HONORED BY HOSPITAL
At a recent meeting of the board of directors of
Baptist Hospital, Dr. Oscar W. Bethea was pi’e-

566

Louisiana State Medical Society News

sented with a silver plaque in recognition of his
19 years of professional services to the hospital.

o

MEDICAL TOASTMASTERS
At recent ceremonies of the Medical Toastmas-
ters, at which time the Charter of Toastmasters
International was presented, Dr. Daniel J. Murphy
was elected president; Dr. P. L. Querens, vice-
president; Dr. Eugene Countiss, secretary-treas-
urer; Dr. C. J. Tripoli, sergeant-at-arms; Dr.
Charles Bahn, deputy governor. Dr. Val Fuchs,
out-going president, was presented with a silver
bowl.

o

NEWS OF MEMBERS' IN MILITARY SERVICE
Major Hardee Bethea has recently returned from
overseas duty. He is now stationed at Regional
Hospital, Camp Swift, Texas.

Edward S. Bres, Jr., an intern member, was
recently placed on the military rolls of the Society.

o

AMERICAN RED CROSS WAR FUND
The physicians went over the top in the recent
campaign to raise funds for the American Red
Cross. Our quota was set at $10,000; the amount
reported through the Physicians Division was
$10,200.

We wish to thank you for your generosity.

C. J. BROWN, M. D., Chairman,
Physicians Division
o

DE PAUL SANITARIUM STAFF MEETING
The following report was received from Dr.
Louis J. Dubos, Secretary:

The regular monthly meeting of the Medical
Staff of De Paul Sanitarium was called to order at
8:10 p. m. with Drs. Golden, Blum, Holbrook, Otis,
May, Unsworth, Thompson, Watters, H. Colomb,
A. Colomb, Friedrichs and Dubos in attendance
and Connely and Anderson excused.

The scientific part of the program started with
Dr. Holbrook presenting Case No. 3817(Mrs. A. L.)
white, female, age 64 years and diagnosed involu-
tional melancholia. She had been sick for about
one month previous to admission to De Paul, great-
ly disturbed, agitated, depressed and worried over
her three sons in the service. After ten electro-
shock treatments she greatly improved, showing
now only memory defect. This case was discussed
in detail by Drs. Golden and Otis.

Next Dr. Holbrook presented Case No. 3707
(Mrs. B. P.) an extremely obese, white female,
57 years of age, who was mentally ill in 1927 for
eight months but who recovered. On January 27,
1945, she again became ill; was suspicious, fright-
ened and melancholic and attempted suicide by
slashing her wrists and neck with a razor, after
which she was transferred to De Paul. Physical
examination revealed marked obesity, cardiac hy-
pertrophy and a hypertension of 250/120. After
combined medical and electroshock therapies she
seems much improved, blood pressure dropped to
160/80 and although still somewhat manic she
seems clear at times and was practically normal
for one day. This case was discussed by Drs.
Golden, Dubos, Watters, A. Colomb and Otis with
some difference of opinion between the diagnoses
of manic depressive vs. arteriosclerotic psychoses.

Dr. Unsworth next briefly summarized three
clinical cases seen at other private institutions,
illustrative of psychosomatic medicine. All proved
extremely interesting.

Dr. Friedrichs, Chairman of the Library Com-
mittee, stated that he had written a letter to the
various Staff Members asking for suggestions re-
garding library material but up to the present
time he has received no answers. Dr. Holbrook
voiced the opinion that standard works and mono-
graphs would form a firm foundation on which to
build and Dr. Friedrichs concluded by stating that
another meeting of his Committee would be held
before the next Staff Meeting.

Dr. Otis then read the reports of the Records
Committee which proved satisfactory.

Next Drs. Holbrook and H. Colomb of the Spe-
cial Liaison Committee said that two meetings had
been held by them and they suggested running an
advertisement in the Southern Medical or the New
Orleans Medical and Surgical Journal with a spe-
cial footnote outlining the rules and regulations
regarding admissions to De Paul. Dr. Otis ob-
jected to this suggestion on the grounds that it
might be construed by some as publicity. He pre-
ferred mailing a printed brochure to the various
physicians, and Sister Anne arose to state that she
too favored a neatly printed brochure with the
names of the Staff Members and Consultants
included thereon and the rules and regulations
therein.

There being no further business, the meeting
was adjourned at 10:15 p. m. followed by the
serving of sandwiches and refreshments.

LOUISIANA STATE MEDICAL SOCIETY NEWS

CALENDAR

Society

East Baton Rouge

Morehouse

Orleans

PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS

Date Place

Second Wednesday of every month Baton Rouge

Second Tuesday of every month Bastrop

Second Monday of every month New Orleans

Louisiana State Medical Society Neivs

567

First Thursday of every month
First Monday of every month
First Wednesday of every month
Third Thursday of every month
First Tuesday of every month
First Thursday of every month

Monroe

Alexandria

Shreveport

Ouachita
Rapides
Sabine

Second District
Shreveport
Vernon

OUACHITA PARISH MEDICAL SOCIETY

The following officers for 1945 were recently
elected by the Ouachita Parish Medical Society:
President, Dr. George A. Varino; Vice-President,
Dr. W. E. Jones; Secretary-Treasurer, Dr. Wil-
liam L. Bendel, all of Monroe.

o

IBERVILLE PARISH MEDICAL SOCIETY

The annual meeting of the Iberville Parish Medi-
cal Society was held at the home of its President,
Dr. Edward C. Melton. The following officers were
elected: President, Dr. Simon C. Levy; Vice-Presi-
dent, Dr. R. D. Martinez; Secretary-Treasurer,
Dr. R. J. Spedale.

Rhodes J. Spedale, M. D,,

Secretary-Treasurer

o

NEWS ITEMS

Among other speakers on the program of the
Louisiana Tuberculosis Association was Dr. P. T.
Talbot, Secretary-Treasurer of the Louisiana State
Medical Society, who gave a talk to the attendants
at the meeting.

Dr. H. 0. Colomb recently addressed the Junior
League of New Orleans on the problems of mental
health in Louisiana.

Scholarships have been offered by the National
Foundation for Infantile Paralysis for training of
physical therapists. The Surgeon Generals of the
Army and Navy both point to the inadequacy of
the present supply of physical therapists who will
be needed more and more as the wounded return
from fighting areas. Applications for scholarships
should be made to the National Foundation, 120
Broadway, New York 5, New York.

The next written examination for Fellowships
in the American College of Chest Physicians will
be held in Chicago, June 16.

Dr. Francis James Cox, Fellow in Orthopedic
Surgery and head of the Orthopedic Division of
the Tulane Base Hospital No. 24, has been pro-
moted to the rank of colonel. Colonel Cox came to
New Orleans in 1940 after having been a resident
in orthopedics in the Hospital for Ruptui’ed and
Crippled Children in New York, followed by a six
months’ residence at the Hillman Hospital, Bir-
mingham. He has been with the unit since the
time of its organization.

Dr. George E. Burch, Associate Professor of
Experimental Medicine, Tulane University School
of Medicine, New Orleans, La., has been appointed
Civilian Consultant to the Surgeon General for
diseases of peripheral blood vessels with particular
emphasis on trench foot and allied conditions.

Lieut. Col. Michael E. DeBakey, MC, Chief of
the General Surgery Branch, Surgical Consultants
Division, Office of the Surgeon General, returned
this month from an overseas observation tour which
included Italy, France, Germany and England.

o

COLONEL ODOM HONORED

Charles B. Odom has been awarded the Bronze
Star Medal. The citation read as follows:

“Colonel Charles B. Odom, 9480718, Medical
Corps, Headquarters Third United States Army.
For heroic achievement in connection with military
operations against an enemy of the United States
in Germany. On 6 April 1945, Colonel Odom, As-
sistant Surgeon, Headquarters Third U. S. Army,
voluntarily undertook a daring mission behind
enemy lines to give medical aid to wounded allied
prisoners held in a prisoner of war camp at Ham-
melburg, Germany. Traveling at night by quarter-
ton truck braving enemy sniper and mortar fire
and the constant threat of ambush he reached the
camp successfully and aided a Serbian medical
officer in treating the wounded. The courage and
skill and loyal devotion to duty Colonel Odom dis-
played are in keeping with the highest traditions
of the military service.

“By command of Lieutenant General Patton.”

At an Inter-Allied Conference on War Medicine
convened by the Royal Society of Medicine, and of
which H. M. The King was Patron, Colonel Odom
spoke on “Vascular Surgery in U. S. Army Ech-
elons.”

o

THE CIRCLE

Election to membership in the Circle, under-
graduate honor scholastic society at Louisiana
State University School of Medicine, was announced
at a meeting April 25, 1945, at which Dr. Norman
Conant, Associate Professor of Bacteriology and
Mycology at Duke University School of Medicine,
was the guest speaker.

New members from the junior class are David
W. Aiken, Joe F. Simpson and Dorothy J. York.
New members from the senior class are Walter J.
Hollis, Edwin Byer, Harold J. Jacobs, William R.
Scarborough and James C. Burns.

Dr. P. Jorda Kahle, Professor and Director of

568

Louisiana State Medical Society News

the Department of Urology at the School of Medi-
cine, was elected an honorary member and was
guest speaker at the banquet held by the Circle
at 8:00 p. m. April 25.

Dr. Donald Duncan, Professor of Anatomy, was
elected to membership on the Faculty Advisory
Committee of the Circle.

o

SOUTHERN BAPTIST HOSPITAL

The regular monthly meeting of the staff of
Baptist Hospital was held Tuesday, April 24. The
program consisted of a most interesting presenta-
tion of cases by the residents and interns. Follow-
ing this there was a talk on parenteral amino acid
therapy by Mr. Daniel R. Borgen, research chemist
of Baxter Laboratories. In a discussion of the
death report special emphasis was placed on the
Waterhouse-Friederichsen syndrome and agranu-
locytosis resulting from thiouracil medication.

o

TOURO INFIRMARY

The regular monthly meeting of the Medical
Staff of Touro Infirmary was held Wednesday,
May 9, at 8 p. m. The program was put on by the
resident staff. The clinico-pathologic conference
was held under the supervision of Dr. Charles
Miller, with a discussion by Dr. George Schneider.
Following this, Dr. Edward Crawford gave a case
report of plasmochin poisoning. Dr. Irving Levin
gave a preliminary report on the intravenous use
of histamine diphosphate in peripheral vascular
disease. Dr. Theo Middleton reviewed the cases of
ectopic pregnancy admitted to the hospital for
1943-44. His presentation was entitled “The Diag-
nosis of Ectopic Pregnancy.”

o

CHARITY HOSPITAL VISITING STAFF

The Medical Division of the Charity Hospital
Visiting Staff held a meeting May 15 in the audi-
torium, to which the following program was pre-
sented: Case presentation by Dr. Chirino with

discussion by Dr. G. Burch; case presentation by
Dr. Gordon Nix with discussion by Dr. Sydney
Jacobs; a case of Banti’s disease by Drs. C. A.
Stewart and J. Colley.

o

RESOLUTION REGARDING PRESCRIBING

Resolution adopted by the House of Delegates at
the annual meeting in 1944, directed to the chair-
man of the Committee on Medical Education:

Whereas, An inspection of the prescription files
of drugstores reveals in many instances carelessly
written or composed prescriptions.

Whereas, In the examination of the Louisiana
State Board of Medical Examiners a woeful lack
of knowledge of the important drugs and dosages,
is noted.

Whereas, These factors cause much criticism and
reflection on the medical profession as a whole.

Be It Resolved that the Louisiana State Medical

Society refer these resolutions to the Committee
on Medical Education with the recommendation
that the Committee endeavor to increase interest
and study of materia medica and therapeutics in
our colleges and profession.

DOCTOR NEEDED

A doctor is needed in Iberia Parish to take over
the practice of medicine in two industrial plants.
Outside practice is permitted, with a basic salary
of $385.00 per month for treating employees. There
is free office space, fully equipped; also one nurse
for an assistant, and a nice home furnished for
$25.00 per month. Anyone interested should get in
touch with the office of the Journal, 1430 Tulane
Avenue, New Orleans 13.

o

INFECTIOUS DISEASES IN LOUISIANA

The morbidity report of the Louisiana State
Department of Health showed that for the week
ending April 7 there were reported the following
diseases in numbers greater than 10: Sixty-nine

cases of tuberculosis, 28 of malaria, 27 of mumps,
24 of scarlet fever, 20 of chickenpox, 19 of measles,
and 18 of influenza. The following week closing
April 14 showed that there were reported 37 cases
of measles, 36 of pulmonary tuberculosis, 35 of
malaria, 20 of chickenpox, 16 each of influenza
and unclassified pneumonia, and 13 of scarlet fever.
The majority of the malaria cases were not re-
ported from military sources, only 12 as a matter
of fact. By parishes 18 of these cases came from
Jackson Parish and 13 from Grant. There was also
listed this week two cases of endemic typhus fever.
For the following week there were only five dis-
eases listed in numbers greater than 10, namely,
37 cases of measles, 24 of pulmonary tuberculosis,
23 of malaria, 19 of mumps, and 14 of unclassified
pneumonia. This week there were 19 cases of ma-
laria listed from military sources, all of them
contracted outside of Continental United States.
For the week which terminated April 28 malaria
led all reportable diseases with 65 cases. However,
19 of these were contracted outside of Continental
United States; the remainder were contracted in
this country. Most of them, 40 in all, were re-
ported from Jackson Parish. Next in order in
frequency was measles with 57 cases, followed by
tuberculosis 41, influenza 21, hookworm and un-
classified pneumonia 18 each, chickenpox 16, scarlet
fever 15, and mumps 12. For the first time in a
long while a case of smallpox was recorded, appar-
ently arising in East Baton Rouge Parish. There
were six cases of typhus fever. So far this year
typhus fever and typhoid fever have the same
incidence.

• o

HEALTH IN NEW ORLEANS

The Bureau of the Census, Department of Com-
merce, reported that for the week ending April 14

Louisiana State Medical Society News

569

there were 123 deaths in the City of New Orleans,
divided 81 white, 42 colored, and of these total
deaths six were in children under one year of age.
This is a slight increase in the number of deaths
occurring in the previous week and slightly above
the three-year corresponding week average. For
the week which closed April 21 there was a sharp
drop in the number of deaths, only 100 occurring
in New Orleans separated 64 white, 36 colored,
with eight infant deaths. The number of deaths
was way below the three-year corresponding aver-
age. For the week ending April 28 there were 121
deaths in the city of whom 98 were white people
and 43 colored. Seven of the deaths were in chil-
dren under one year of age. For some peculiar
reason the three-year average for this particular
week is 150 deaths in the city, whereas in the next
week there were only 115 in the City of New
Orleans. The first week in May revealed the deaths
of 127 patients in New Orleans, divided 84 white,
43 colored, and 11 in infants under one year of age.

o

V-E DAY MEANS BIGGER TASK FOR
ARMY MEDICAL DEPARTMENT
The ending of hostilities in Europe means that
the doctors, nurses, technicians and other personnel
who comprise the Army Medical Department will
now begin an even bigger job than they have been
doing which means there is no immediate prospect
for the general release of personnel, Major Gen-
eral Norman T. Kirk, the Surgeon General, de-
clared on V-E Day.

The Medical Department, he pointed out, not
only must continue to care for the sick and wound-
ed but must make immediate preparations for the
redeployment of troops to the Pacific or this
country.

One of the biggest tasks will be to give physical
examinations to some 3,500,000 soldiers before they
leave Europe. In addition, a goal of 90 days has
been set in which to evacuate the sick and wounded
from the European theater to this country. Then
there will be the final matter of redeploying the
Medical Department personnel and equipment.

Soldiers whose condition necessitates a medical
discharge will be given further treatment and nec-
essary examinations in the United States. All sol-
diers, prior to discharge from the service, will be
screened for tuberculosis, syphilis and other dis-
eases, and for possible strains and other physical
defects. Thus hospitals here will probably be oper-
ating at capacity with a critical need for medical
personnel for many months to come.

“Practically all officers and men in the Medical
Department came in for the emergency,” said the
Surgeon General, “and so far as we are concerned
the emergency is far from being over.”

| o — f

“SOCIAL SECURITY” NEEDLE

Editorial, comment has been made in the past in
referebc'e to the enormous taxation that will be

necessary to carry out many of the proposed social
security benefits. To substantiate what has been
written, we would like to reproduce an editorial
that appeared in the Times-Picayune on May 18
under the above caption :

“Senator Wagner is reported to be preparing to
introduce bills for vast expansion of the so-called
‘social security’ program. If the outline given of
his plans is correct, they mean the imposition of
new gross income taxes, on top of war taxes, of
three per cent, both for employers and employes.
The field of taxation would be extended to 15,000,-
000 persons employed in domestic and farm work
and in nonprofit institutional work, and to their
employers; and likewise to the self-employed.

“Part of the extra tax money, under these re-
ported proposals, would be used to finance in-
creases in current unemployment, old-age and aid
outlays — provision of medical and hospital care to
all workers and their families; increase of weekly
unemployment payments to $30; provision of both
temporary and total disability payments; and re-
duction of the old-age eligibility requirement for
women from 65 to 60 years.

“The part of the increased revenues which would
go to current disbursements is not given. It can
readily be increased, under the inflationary mania,
by rising costs and continual upward revision of
the benefit payments. The last process is a bucket
without a bottom, or a cone without a top, once
the pressure begins.

“Theoretically the increased benefits proposed
could be provided temporarily from the accrued
social security ‘fund.’ There is however no such
fund in cash, or productive property; it exists in
bonds which are serviced by current taxation.
Every dime of the proposed increased ‘social se-
curity’ taxes over and above current disbursements
will go into the same fund. Proceeds from that
investment will be spent for other current govern-
ment needs and obligations.

“Thus all surplus from the heavy ‘social security’
taxes will become government revenue, expended
for general purposes on the current scale of high
costs and prices. Should the fund itself ever be
called upon to meet a real unemployment emer-
gency, the people will find that to liquidate and
make available the bonds, ‘all’ they will have to do
is pay the necessary extra taxes to liquidate them.
They will tax themselves all over again to sustain
their unemployed et al. The name of ‘security’ for
the latter has been taken in vain long enough.”

DR. JAMES THOMAS NIX
(1887-1945)

One of New Orleans’ distinguished physicians
died Thursday, May 17. Dr. James T. Nix was
known not only in New Orleans but throughout the
state. At various times he was the dean of the
Louisiana State University Graduate School of
Medicine, director of the Tumor Clinic at Charity

570

Book Reviews

Hospital, medical director of Higgins Industries,
Inc., past president of the Catholic Physicians’
Guild, past president of the Orleans Parish Medi-
cal Society and a vice-president of the Louisiana
State Medical Society. Dr. Nix was an honorary
life fellow of the American College of Surgeons

and had been knighted by the Pope into the Civil
Order of St. Gregory. One of the most active
physicians in New Orleans, Dr. Nix was a forceful,
able surgeon and leaves behind him a heritage of
splendid accomplishments.

■0

BOOK REVIEWS

Clinical Heart Disease: By Samuel A. Levine,
M. D., F. A. C. P., Philadelphia and London,
W. B. Saunders Company, 1945. 3rd ed.. Rev.
462, illustrations. Price, $6.00.

Dr. Levine is unique among medical authors for
his lucid and entertaining style. The fact that a
third edition of this very popular book has been
published is ample testimony of the value and the
favorable reception accorded everywhere by the
medical profession to the preceding editions. Dr.
Levine has brought the book up-to-date with the
recent developments in cardiovascular disease. It
can be highly recommended to the clinician and
student alike as a reliable authority on the subject.

Roscoe L. Pullen, M. D.

Atlas of the Blood in Children: By Kenneth D.
Blackfan, M. D. and Louis K. Diamond, with il-
lustrations by C. Merrill Leister, M. D. New
York, The Commonwealth Fund, 1944. Illus.,
pp. 320. Price, $12.00.

The origin of the cellular elements of the blood
is described in the opening chapter. The poly-
phyletic theory of Sabin is followed. The erythro-
cytes in anemia are classified on a cytological basis;
that is, according to size and hemoglobin content.
Their classification on this basis consists of five
groups. Each type of anemia in each group is
then discussed following a standard form which
consists of definition, theories as to etiology, symp-
toms and signs, laboratory data, diagnosis, course
and prognosis, and treatment. A typical case re-
port is then given.

Erythroblastosis fetalis is covered in detail. The
significance of leukocytosis and leukopenia is dis-
cussed. Infectious mononucleosis is then described
following the outline given above. Leukemia is
discussed with little attempt at classification, the
different types being illustrated by case reports.
Diseases of the platelets are described using the
usual outline.

An extensive 13 page bibliography is included.
Seventy plates by Dr. Leister are presented, each
with a complete key. These plates illustrate matu-
ration of red cells, white cells, and platelets, and
each of the diseases discussed in the subject mat-
ter. The plates are grouped together in the back
of the book with an index.

The subject matter is brief but well presented.
It should appeal to the pediatrician, for the meth-
ods of diagnosis, interpretation of blood findings

and treatment are complete enough for most of the
blood dyscrasias in children. The plates should be
of particular interest to the hematologist. Cellu-
lar cytology, as seen in smears stained by Wright’s
method, is accurately reproduced. The grouping
of the plates in the back of the book makes them
very accessible.

F. C. Coleman, M. D.

Patients Have Families: By Henry B. Richardson,

M. D., F. A. C. P., New York, N. Y., The Com-
monwealth Fund, 1945. Pp. 408. Price, $3.00.

This volume emanating from the department of
preventive medicine and public health of Cornell
University will probably achieve the author’s aim
in stimulating social and welfare workers to reali-
zation of the “extraordinary” fruitfulness of the
understanding of the family unit. The prepara-
tion of this work must have required unusual
thought and a thoroughness of survey for it is
most meticulous in detail. The reviewer is im-
pressed with the extensive evaluation of each angle
of conflict which in our social and economic struc-
ture contributes to disease.

It is rare that a physician, especially an inter-
nist or psychiatrist, is not sufficiently cognizant
of the relation of surrounding environment to our
patient and his reaction to disease. It is not un-
likely that in many instances such is given too
great prominence in our decision. Few physicians
will find this work interesting reading for the
author is too impractical in his wanderings
through family life and has not conserved thought
nor space. The reviewer doubts that many lay
persons, even of unusual mental endowment, could
find the work easy or instructive reading. There-
fore the usefulness of the work is limited to a
relatively small group who devote their efforts to
social and welfare work.

To those who dwell in the intimacies of the so-
cial and economic structure of our clinic patients
this volume will be a source of joy as a text and
research volume. It will be most useful in in-
struction of students.

What I have stated above should not be con-
strued as criticism of the work itself for my issue
is on the practicability as applied to the physician
himself. The preparation, the presentation and
the research are all remarkably well done. The sim-
plicity of the description of behavior 'patterns is
easily understandable to any reader.

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